^ i > ' 



•f) 



hh. 




Class BxlM 
Book 



A 



Goipgliffl^- 



COPn^IGHT DEPOSm 



I ;PO 



DESCRIPTION OF FRONTISPIECE. 



_±h 



H6^<e 



SIDE VIEW OF THE FEMALE PELVIS (Fig. 1). 



B. Bladder (turned down). 

R. Rectum. 

L. Round ligament. 

U. Uterus. 

0. Ovary. 
V. Vagina. 

S. Saero-iliac synchondrosis. 

K. Kidney. 

T. Fallopian tube. 

P. Pubic symphysis. 

a. Pyriformis muscle (cut)! 

h. Gluteal muscles. 

c. Coecygeus muscle. 

d. Obturator internus. 

e. Psoas magnus. 
/'. Liuea alba. 

g,g. Ureters. 
//. Obturator nerve. 
/. Internal abdominal ring. 
k. Great sacro-sciatic ligament. 

1. Abdominal aorta. 



2. Interior mesenteric artery, 
3, 3. Common iliac arteries. 

4. Left external iliac artery. 

5. Vena cava inferior. 

6, 6. Renal veins. 

7, 7. Common iliac veins. 

8. External iliac vein. 

9. Internal iliac artery (cut). 

10. Gluteal vein. 

11. Ilio-lumbar vein. 

12. Lateral sacral vein. 

13. Sciatic vein. 

14. Pudic vein. 

15. Obturator vein. 

16. Epigastric vein. 

17. Uterine veins. 

18. Vesico-vaginal veins. 

19. Ovarian veins. 

20. Bulb of the ovary. 

21. Vein to round ligament. 

22. Fallopian veins. 



FEMALE PERINEUM AND ISCHIO-RECTAL REGION (FiG. 2). 



8: 



10. 

11. 

12. 
13. 
14. 
15. 



Coccyx. 

Gluteus maxinius. 

Fascia lata, inserted into pubic arch. 
Tuberosity of ischium. 
Internal sphincter ani. 
External sphincter ani. 
Attachment- of sphincter ani to coccyx. 
Levator ani, forming floor of isehio 
:* fossa. 
^rineum. 

Transversus peronei muscle. 
Erector clitoridis. 
Constrictor vaginee. 
Glands of Bartholini. 
Urethral opening. 
Labia majora. _ 



10. Labia minora. 

17. Clitoris. 

18. Muns Veneris. 

19. Internal pudic artery. 

20. External hemorrhoidal artery. (The three arte- 
i ries of this name are shown, the middle one 
I only being marked.) 

■rectal ' 21. Superficial perineal artery. (Supplying anus, 
perineum, vaginal lips, and erector clito- 
ridis.) 

22. Transversus peronei artery. 

23. Deep branch of internal pudic nrtery. 

24. Artery of the bulb (arteria btdbosa). 

25. "Internal pudic vein (common). 

26. External hemorrhoidal vein, (Other liranches 
of the same vessel not marked.) 



AN AMERICAN 



TEXT-BOOR OF GYNECOLOGY, 



MEDICAL AND SURGICAL, 



FOR 



PRACTITIONERS AND STUDENTS 



BY 

HENRY T. BYFORD, M.D., J. M. BALDY, M.D., 

EDWIN B. ORAGIN, M.D., J. H. ETHEKIDGE, M.D., 

WILLIAM GOODELL, M.D., HOWARD A. KELLY, M.D., 

FLORIAN KRUG, M.D., E. E. MONTGOMERY, M.D., 

WILLIAM R. PRYOR, M.D., GEORGE M. TUTTLE, M. D. 



EDITED BY 

J. M. BALDY, M.D. 



WITH 360 ILLUSTRATIONS IN TEXT, AND 37 COLORED 
AND HALF-TONE PLATES. 



. PHILADELPHIA: 

W. B. SAUNDERS, 

925 Walnut Street. 

1894. 




S-Srf^ J -J/ 



4 



\ 





V 

8^^ 



Copyright, 1893, by 
W. B. SAUNDERS 



ELECTROTVPED BY 

WESTCOTT & THOMSON, PHILADA. 



PRINTED BY 
W. B. SAUNDERS. PHILADA. 



TO THE 

MEDICAL PROFESSION OF AMERICA, 

BY 

THEIR CO-WORKERS, 
THE AUTHORS. 



LIST OF AUTHORS. 



J. M. BALDY, M. D., 

Professor of Gynecology in the Philadelphia Polyclinic ; Gynecologist to the Hospital of 
the Philadelphia Polyclinic ; Surgeon to the Gynecean Hospital ; Gynecologist to the 
Pennsylvania Hospital. 

HENRY T. BYFORD, M. D., 

Professor of Gynecology in the College of Physicians and Surgeons, Chicago, and in the 
Post-Graduate Medical School of Chicago ; Gynecologist to the Women's and St. Luke's 
Hospitals, Chicago. 

EDWIN B. CEAGIN, M. D., 

Fellow of the New York Academy of Medicine ; Assistant Gynecologist to the Hoosevelt 
and New York Cancer Hospitals. 

JAMES H. ETHERIDGE, M. D., 

Professor of Gynecology and Obstetrics in the Rush Medical College, Chicago, and in 
the Chicago Polyclinic ; Gynecologist to the Presbyterian Hospital ; Consulting Gyne- 
cologist to the St. Joseph's Hospital, Chicago. 

WILLIAM GOODELL, M. D., 

Professor of Gynecology in the University of Pennsylvania, Philadelphia. 

HOWARD A. KELLY, M. D., 

Professor of Gynecology and Obstetrics in the Johns Hopkins University, Baltimore; 
Gynecologist and Obstetrician to the Johns Hopkins Hospital. 

FLORIAN KRUG, M. D., 

Professor of Gynecology in the New York Polyclinic; Visiting Gynecologist to the 
German Hospital, New York. 

E. E. MONTGOMERY, M. D., 

Professor of Clinical Gynecology in the Jefferson Medical College, Philadelphia; Gyne- 
cologist to the Jefferson Medical College Hospital and St. Joseph's Hospital ; Obstetri- 
cian to the Philadelphia Hospital. 

WILLIAM R. PRYOR, M. D., 

Adjunct Professor of Gynecology in the New York Polyclinic ; Visiting Gynecologist to 
the St. Elizabeth Hospital and Visiting Physician to the Charity Hospital, New York. 

GEORGE M. TUTTLE, M. D., 

Professor of Gynecology in the College of Physicians and Surgeons, New York ; Attending 
Gynecologist to the Roosevelt Hospital ; Consulting Surgeon to the New York Cancer 
Hospital and New York Infirmary for Women and Children. 

vii 



PREFACE. 



The rapid and progressive advances in the science and art 
of Gynecology during the past dozen years have created an 
almost constant necessity for the revision of works on this sub- 
ject. For this reason, and for the purpose of presenting gyne- 
cological surgery and treatment as it is practised in America, the 
country of its birth and of its most substantial improvements 
and progress, the present text-book has been prepared by Amer- 
ican authors, all of whom are teachers of this branch of surgery 
in the leading medical schools and hospitals. It is thoroughly 
practical in its teachings, and is intended, as its title implies, to 
be a working text-book for physicians and students. Many of 
the most important subjects are considered from an entirely 
new standpoint, and are grouped together in a manner some- 
what foreign to the accepted custom. Several new chapters have 
been added, such as Technique and After-treatment, it being 
hoped that by this presentation of the subject the student might 
the more readily be aided in an intelligent understanding of 
their details. Illustrations have been depended upon in great 
measure to demonstrate and explain the anatomy of the parts 
considered — a method of dealing with the subject which has 
relieved the text of much irrelevant and cumbersome matter. 

The work embodies as nearly as possible the combined opinions 
of all the authors, although it is to be understood that each indi- 
vidual author must be free from absolute responsibility for any 
particular statement: especially is this so for the reason that 
the Editor has endeavored by adding to and subtracting from 
the text to render it as uniform in its statements as possible. 



X PREFACE. 

All extraneous matter and discussions have been carefully ex- 
cluded, and the attempt has been made to allow nothing unneces- 
sary to cumber the text, which is brought fully up to date at every 
point. 

The subject-matter of this work has been enforced by illustra- 
tions wherever opportunity presented. A large proportion of these 
illustrations are original, and are mostly reproduced from photo- 
graphs or from fresh specimens. A considerable number of wood- 
cuts and several half-tone and colored plates have been taken from 
other authors, and are credited to them in the List of Illustrations. 

The Editor desires to thank Dr. Frank W. Talley for his 
careful revision of the proof-sheets, for his preparation of the 
Index, and for his valuable aid in other ways, and to express 
appreciation of the efficient and ever-ready co-operation of Mr. 
W. B. Saunders. 

J. M. BALDY. 

Philadelphia, Dec. 1, 1893. 



CONTENTS. 



PAGE 

EXAMINATION OF THE FEMALE PELVIC ORGANS 17 

THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS 54 

MENSTRUATION AND ITS ANOMALIES ... 81 

STERILITY 123 

ANOMALIES OF THE FEMALE GENERATIVE ORGANS 130 

GENITAL TUBERCULOSIS 144 

DISEASES OF THE VULVA AND VAGINA 164 

INFLAMMATORY DISEASES OF THE UTERUS 202 

LACERATION OF THE SOFT PARTS 245 

GENITAL FISTULA 267 

DISTORTIONS AND MALPOSITIONS 278 

MALIGNANT DISEASES OF THE FEMALE GENITALIA 351 

UTERINE NEOPLASMS 398 

PELVIC INFLAMMATIONS 437 

ECTOPIC GESTATION 518 

DISEASES OF THE OVARIES AND TUBES 544 

DISEASES OF THE URETHRA, BLADDER AND URETERS 615 

AFTER-TREATMENT IN GYNECOLOGICAL OPERATIONS 660 

xi 



LIST OF ILLUSTRATIONS. 



FIG. PAGE 

1. The Allison Gynecological Table, arranged for the Dorsal Position 19 

2. The Allison Gynecological Table, arranged for the Left Lateral Position ... 19 

3. The Indianapolis Gynecological Chair, arranged for Dorsal and Lateral Posi- 

tions 20 

4. Gynecological Cabinet 20 

5. Arrangement for Office Examination and Treatment (Byford) ........ 21 

6. Normal Position of the Uterus (Byford) 24 

7. Direction of the Ureters (Byford) 25 

8. Digital Eversion of the Kectum (Thomas and Munde) . 26 

9. Palpation of the Coccyx (Byford) 26 

10. Kectal Palpation of the Uterus, drawn down by a Vulsellum Forceps (Byford) . 27 

11. Bimanual Palpation of the Uterus (Byford) 28 

12. Bimanual Eectal Palpation of the Pelvis (Byford) 30 

13. Bimanual Recto- vaginal Palpation of the Uterus (Byford) 31 

14. Simpson's Uterine Sound 33 

15. Sims's Uterine Sound 33 

16. Jenks's Uterine Sound 33 

17. Thomas's Hard-rubber Probe 33 

18. Curves of the Uterine Sound to Facilitate Introduction (Byford) 34 

19. Sims's Uterine Elevator • 35 

20. Elliott's Uterine Elevator 35 

21. Emmet's Uterine Elevator 35 

22. Replacement of the Uterus with the Sound. First Motion (Byford) 36 

23. Replacement of the Uterus with the Sound. Second Motion (Byford) .... 36 

24. Byford's Uterine Elevator 37 

25. Action of Byford's Uterine Elevator (Byford) 37 

26. Sims's Retractor 38 

27. Sims's Speculum .38 

28. Sims's Double-end Depressor 38 

29. Sims's Speculum, introduced (Byford) 39 

30. Tenaculum \ 39 

31. Byford's Uterine Dressing Forceps 39 

32. Bozeman's Uterine Dressing Forceps 40 

33. Emmet's Uterine (silver) Applicator 40 

34. Goodell's Speculum 40 

35. Talley's Speculum 40 

36. Higbee's Speculum 41 

37. Brewer's Speculum • 41 

38. Taylor's Speculum 41 

39. Nott's Trivalve Speculum 42 

40. Nelson's Trivalve Speculum 43 

xiii 



xiv LIST OF ILLUSTBATIONS, 

FIG. PAGE 

41. Fergusson's Speculum 43 

42. Higbee's Speculum, introduced (Byford) 44 

43. Passage of the Uterine Sound in case of Eetro version and Anteflexion (Byford) . 44 

44. Simon's Retractors ; Removable Aseptic Handles and Joints 45 

45. Jackson's Perineal Retractor ♦ 46 

46. Byford's Lateral Vaginal Retractor 46 

47. Elm Tent, whittled from fresh slippery-elm bark (Byford) 47 

48. Elm Tent, after being moistened and bent, ready for introduction (Byford) . . 47 

49. Hank's Uterine Dilator 48 

50. Nott's Dilator 48 

51. Goodell's Dilator 49 

52. Sponge Tents 49 

63. Tupelo Tents (Munde) . 50 

54. Laminaria Tents (Munde) 51 

55. Laminaria Tents dilated in the Uterus, showing Constriction by the Internal 

Os (Munde) 51 

56. Palpation of the Interior of the Bladder (Winckel) 52 

57. Wire Curette . - 52 

58. Exploratory Curette 52 

59. Exploratory Needle and Syringe 53 

60. Sterilizer, Demijohn, Basin-holder, Sponges, Drainage-tubes, Syringes, Sutures, 

etc. (Baldy) 57 

61. Instrument Table with Glass Trays (Kelly) 58 

62. Sink, Sterilized Water, Arnold's Sterilizer, etc. (Kelly) ...» 58 

63. Instrument Case and Sterilized Water in Bottles (Kelly) 59 

64. Etherizing Room. Patient being Etherized (Kelly) 60 

65. Sterilization of Hands. Costume of Operator and Assistants (Kelly) .... 62 

66. Washing away Permanganate of Potash with Oxalic- Acid Solution (Kelly) . 63 

67. Placing Instruments in Arnold's Sterilizer, in Linen Bag (Kelly) 64 

68. Silk in Tubes for Sterilization (Kelly) 65 

.69. Mikulicz Drain (Montgomery) 68 

70. Gauze Drains (Kelly) 69 

71. Glass Drainage-tube 70 

72. Hard-rubber Syringe, for cleansing drainage-tube 70 

73. Kelly's Leg-holder 71 

74. Robb's Modification of Kelly's Leg-holder 71 

75. Assistant supporting Legs (Kelly) 72 

76. Perineal Pad in Position (Kelly) 73 

77. Fountain Syringe used for Irrigation in Private Practice . 73 

78. Glass-jar Irrigator (Kelly) 74 

79. Baldy's Irrigating Tube 74 

80. Operating Table with Ovariotomy Pad in Position (Kelly) . 75 

81. Opening the Peritoneum (Kelly) 76 

82. Short Incision in the Abdominal Wall (Kelly) 77 

83. Method of Enlarging the Abdominal Incision (Kelly) 78 

84. Occlusive Dressing of the Abdominal Wound (Kelly) 80 

85. Vertical Section through the Mucous Membrane of the Uterus (Turner) ... 92 

86. Menstrual Endometrium (Weber) 92 

87. Menstrual Pad . ; 97 

88. Membranes of Membranous Dysmenorrhea (Simpson) 113 

89. Apparatus for Artificial Impregnation (VuUietet Lutaud) 129 

90. Development of the External Genital Organs (Schroeder) 130 

91. Malformation of the External Genital Organs (Schroeder) 130 



LIST OF ILLUSTRATIONS. xv 

FIG. PAGE 

92. Pseudo-hermaphrodism proper (Pozzi) . 133 

93. Pseudo-hermaphrodism proper (Pozzi) 134 

94. Solid Rudimentary Uterus (Forster) 138 

95. Uterus Bipartitis (Rokitansky) 138 

96. Infantile Uterus (Schroeder) 138 

97. Uterus Unicornis (Schroeder) 139 

98. Uterus Bicornis (Schroeder) 139 

99. Bicorn Unicervical Uterus (Barnes) 140 

100. Uterus Septus (Kussmaul) 140 

101. Didelphis Uterus and Divided Vagina (Oliver) 141 

102. Lupus Hypertrophicus et Perforans of the Vulva {Arch, fur Gynecologie) . . 145 

103. Lupus of the Vulva (^rcA. /iir Gynecologie) 146 

104. Tuberculosis of the Oervix Uteri (Cornil) 148 

105. Tubercular Pyosalpinx with Tubercular Ovary (Baldy, from photograph in 

possession of Dr. B. C. Hirst) 152 

106. Hypertrophy of the Clitoris (Tait) 165 

107. Follicular Vulvitis (Auvard) . 168 

108. Normal Vulvo-vaginal Gland (Tarnier) 169 

109. Simple Vegetations of the Vulva (Tarnier) 174 

110. Plexus of Veins of the Vestibule (Kobelt) 175 

111. Hernia Labialis Inguinalis (Winckel) 178 

112. Hernia Vaginalis Labialis (Winckel) 179 

113. Hernia Vaginalis Labialis, extending into the Labium Majus (Winckel) . . 179 

114. Elephantiasis of the Labia (Scanzoni) 180 

115. Fibroid of the I^eft Labium Majus (von Schiele) 181 

116. Cyst of the Right Labium Majus (Baldy, from photograph in possession of 

Dr. B. C. Hirst) 182 

117. Cystic Tumor of the Clitoris (Meigs) 182 

118. Tumor of the Clitoris (Emmet) 183 

119. Adipose Tumor of the Left Labium (Goodell) 183 

120. Fibro-papillary Hypertrophy of the Hymen in a case of Vaginismus (Winckel). 186 

121. Sims's Vaginal Dilator 187 

122. Atresia of the Hymen (Breisky) . 188 

123. Complete Occlusion of the Vagina (Barnes) 188 

124. Hypertrophied Vaginal Wall above an Atresia of the Vagina (Breisky) . . 189 

125. Double Uterus and Double Vagina, w^ith Retention of Menstrual Fluid on 

the Left Side (Byford) 190 

126. Simple Vaginitis (Ruge) 194 

127. Granular Vaginitis (Ruge) 195 

128. Adhesive Vaginitis (Ruge) 195 

129. Emphysematous Vaginitis (Ruge) 196 

130. Cyst of the Posterior Vaginal Wall (Winckel) 200 

131. Fibre of the Endometrium, showing different grades of corpuscular develop- 

ment (Johnstone) 202 

132. Lymphatics of the Uterus (Poirier) 203 

133. Normal Mucous Membrane of the Cervix (Wyder) 204 

134. Transverse Section through the Upper Part of the Cervix, showing the 

entire Mucous Membrane (Cornil) .... - 205 

135. Menstruating Endometrium (Johnstone) 206 

136. Endometrium, showing Corpuscular Exhaustion of the whole Structure: 

Senile Endometrium (Johnstone) 207 

137. Benign Adenomatous Degeneration of the Endometrium, or Hypertrophic 

Glandular Endometritis {Arch, fur Gynecologie) 208 



xvi LIST OF ILLUSTRATIONS. 

FIG. PAGE 

138. Glandular Endometritis; Polypoid Form (Wyder) 209 

139. Diffuse Papillary Adenoma of the Body of the Uterus with Polypi (Winckel) . 210 

140. Section of a Glandular Uterine Polyp (Cornil) 211 

141. Interstitial Endometritis, with complete Atrophy of the Glands (Wyder) . . 212 

142. Puerperal Endometrium removed by Curettement on the seventh day [Arch. 

fur Gynecologic) 217 

143. Cocci from an Empyema; prepared by Gram's Method (Von Jaksch and 

Cagney) = 218 

144. Syringe for removal of Cervical Secretions 218 

145. Gonococci (two days after infection) (Von Jaksch and Cagney) 221 

146. Instruments in Position for Dilatation of the Cervix Uteri (Baldy) 223 

147. Instruments for Curettement of the Uterus 224 

148. Sharp Curette 225 

149. Uterine Applicator 225 

150. Bulb Syringe 226 

151. Braun's Intra-Uterine Syringe 226 

152. Instruments for applying the Intra-Uterine Tampon (Burrage) 226 

153. Tamponing the Uterus with Iodoform Gauze by means of the Intra-Uterine 

Packer (Baldy) 227 

154. Vertical Section of Endometrium three months after curettement [Nouv. Arch. 

d' Obsteirique et de Gyn'ecologie) 230 

155. Vertical Section of the Uterine Mucous Membrane fifty -three days after the 

application of a Caustic [Nouv. Arch, d' Obsteirique et de Gynecologic) . . 231 

156. Perpendicular Section of the Uterine Mucous Membrane thirteen days after 

curettement [Nouv. Arch, d' ObstHrique et de Gynecologic) 232 

157. Perpendicular Section of the Uterine Mucous Membrane thirty-one days 

Siftev curettement {Nouv. Arch, d' Obstetrique et de Gynecologic) 232 

158. Mucous Polypi from the interior of the Cervix and upon the surface (Pozzi) . 236 

159. Simple Papillary Erosion of the Cervix (Pozzi) 237 

160. Simple Follicular Cysts of the Cervix (Auvard) 237 

161. Cone of Tissue removed by Sims's Amputation of the Cervix Uteri (Pryor) . 239 

162. Subinvolution (Cruveilhier) 243 

163. 164. Side and Front Views of a Simple Bilateral Laceration of the Cervix, 

requiring no treatment (Kelly) 246 

165. Front View of an Unilateral Laceration of the Cervix, requiring no treatment 

(Kelly) 247 

166. Side View of an Unilateral Laceration (Kelly) 247 

167. Side View of an Unilateral Laceration of the Cervix, requiring treatment 

(Kelly) 247 

168. Front View of a Bilateral Laceration of the Cervix, showing eroded area 

and Nabothian follicles (Kelly) 247 

169. Tenacula in Place, showing eversion of a lacerated Cervix (Kelly) 247 

170. Tenacula Crossed, showing the method of approximating the lacerated lips 

and demonstrating the true condition (Kelly) 247 

171. Knife-bladed Tenaculum, used in scarifying the Cervix (Kelly) 248 

172. Denudation in the Angles of the Laceration (Kelly) 249 

173. Method of Denudation (Kelly) • . 249 

174. Blade of Knife used in Denudation (Kelly) 249 

175. 176. Silkworm-gut Suture, in place on one side ready to be tied. Front and 

Lateral Views (Kelly) 250 

177. Silkworm-gut Sutures in Place ; intervening approximation of sutures of fine 

silk (Kelly). 251 

178. Virginal Vaginal Outlet (Baldy) 252 



LIST OF ILL USTBA TIONS. xvii 

FIG. PAGE 

179. Relaxed Vaginal Outlet as seen in the Dorsal Position (Kelly) 254 

180. Appearance of Relaxed Vaginal Outlet in Sims's Position (Kelly) 255 

181. Looking down on the Floor of the Pelvis. Dotted lines indicate the area to 

be denuded (Kelly) 255 

182. Area to be Denuded within the Vagina outlined with point of knife (Kelly) . 255 

183. Area of Skin Surface to be denuded, outlined with point of knife (Kelly) . . 256 

184. Drawing or Tension Suture introduced and ready to be tied (Kelly) .... 257 

185. Drawing Suture tied and Superficial Silk Sutures in place (Kelly) 257 

186. Suture tied on Right and in place ready to be tied on Left Side (Kelly) . . . 257 

187. Sutures of both Sides tied and the Crown Sutures in place (Kelly) 258 

188. All Sutures tied, leaving a superficial area to be closed with fine Silk Sutures 

(Kelly). 258 

189. Completed Operation (Kelly) 258 

190. Speculum introduced into Vagina, showing the result of the operation 

(Kelly) 259 

191. Normal Sphincter; no break in the Continuity of the circular fibres (Kelly) . 260 

192. Slight Solution of Continuity in the Sphincter filled in with Connective Tissue. 

No Impairment of functions (Kelly) 260 

193. Sphincter Completely Ruptured, divided ends being widely separated. 

Complete loss of function (Kelly) 260 

194. Solution of Continuity imperfectly bridged over with Connective Tissue. 

Partial loss of function (Kelly) 260 

195. Rupture of the Recto-vaginal Septum (Kelly) 264 

196. Rectal Sutures in Place (Kelly) *. : 265 

197. Rectal Sutures tied, and Sutures in place on the Vaginal Surface (Kelly) . . 265 

198. Sutures within the Vagina tied ; External Sutures in place (Kelly) 265 

199., Shaded Area indicates the extent of the Tear in the Recto-vaginal Septum 

(Kelly) 265 

200. The various forms of Vesical Fistula (Kelly) , 267 

201. Vesico-uterine Fistula (Kelly) \ , 270 

202. Vesico-uterine Fistula divided into two channels by a Septum of Scar-tissue 

(Kelly) • 270 

203. Vesico-utero-vaginal Fistula (Kelly) 271 

204. Vesico- vaginal Fistula; bladder adherent to the uterus along the darkly 

shaded line (Kelly) 273 

205. Operation for Vesico- vaginal Fistula (Kelly) 274 

206. Diaphragm of Pathological Anteflexion (Schultze) 279 

207. Extreme Retroflexion (Barnes) 287 

208. Ventro-recto-vaginal Reduction in Uterine Retrodisplacement (Brandt) . . 290 

209. Bimanual Reposition of the Retroflexed Uterus : first step (Schultze) . . . . 290 

210. Bimanual Reposition of the Retroflexed Uterus : second step (Schultze) . . 291 

211. Bimanual Reposition of the Retroflexed Uterus: elevation of the fundus by 

the internal hand (Schultze) ,. 292 

212. Bimanual Reposition of the Retroflexed Uterus : the external hand taking 

charge of the fundus (Schultze) 293 

213. Bimanual Reposition of the Retroflexed Uterus, completed (Schultze) . . . 294 

214. Baldy's Uterine Repositor 295 

215. Replacement of Retrodisplaced Uterus by means of the Uterine Repositor, 

in the knee-chest position (Baldy) 295 

216. Diagnosis and Reduction of Retroflexion by the Sound (Courty) 297 

217. Sims-Pryor Uterine Repositor 298 

218. Frozen Section of a Girl aged Thirteen Years, showing direction of intra- 

abdominal pressure (Simington) 299 

h 



xviii LIST OF ILLUSTRATIONS. 



FIG. 



PAGE 

219. Waldeyer's Frozen Section of a Female Pelvis (Henle) 300 

220. Smith-Hodge Pessary 302 

221. Smith-Hodge Pessary 302 

222. Solid Rubber-ring Pessary 302 

223. Introduction of Pessary, first stage (Baldy) .303 

224. Introduction of Pessary, second stage (Groom) 303 

225. Introduction of Pessary, third stage (Groom) 304 

226. Introduction of Pessary, fourth stage (Groom) 304 

227. Pessary for Gomplete Prolapse 305 

228. Needle for the Performance of Schucking's Operation 306 

229. Schucking's Operation for Eetrodisplaced Uterus (Baldy) 307 

230. Retroversion of Slight Degree (Winckel) 309 

231. Round Ligament and its Topographical Anatomy (Maclise) . 310 

232. Round Ligament and its Topographical Anatomy (Maclise) 311 

233. Operation Proposed by Wylie and Baer for Retrodisplacement of the Uterus 

(Wylie) 312 

234. Operation Proposed by Dudley for Uterine Retrodisplacement (Baldy) . . . 312 

235. Sutures in Position in Hysterorrhaphy (Baldy) 314 

236. Sutures in situ in the Abdominal Wall after Hysterorrhaphy (Baldy) . . . 315 

237. Varieties of Prolapsus (Kelly) 318 

238. Vertical Mesial Section of Prolapsus Uteri (Hart) 319 

239. Complete Prolapse of the Uterus (Boivin) 320 

240. Complete Prolapsus Uteri, showing ulcer ; also hypertrophy of the mucous 

membrane (Baldy, Yrom photograph in possession of Dr. B. F. Baer) . . 321 

241. The arrow shows the direction of force in case of a normal perineum when 

straining at stool (Prj^or) 322 

242. The perineum, being ruptured, no longer resists, and the resulting condition is 

shown when straining at stool (Pry or) 323 

243. Gystocele and Rectocele (Munde) 323 

244. Showing effect of intra-abdominal pressure on the uterus in anteflexion with 

intact pelvic floor (Kelly) 325 

245. Pelvic Floor broken down, Uterus in retroflexion. Intra-abdominal pressure 

increases the displacement (Kelly) 325 

246. Illustrating the Formation of a Complete Prolapsus (Kelly) 825 

247. Tamponade of the Vagina in the Knee-chest Position (Baldy) 329 

248. Braun's Golpeurynter 329 

249. Stoltz's Operation for Cystocele and Hegar's Operation for Rectocele (Munde). 331 

250. Sutures Tied in Stoltz's Operation for Gystocele. Stitches in place ready for 

tying in Hegar's Operation for Rectocele (Mund6) 331 

251. Elongation of the Infravaginal Portion of the Cervix (Kelly) 335 

252. Emmet's Anterior Colporrhaphy, stitches in situ (Pry or) 335 

253. Profile View of Hegar's Operation of Perineorrhaphy (Pryor) 340 

254. Flap-splitting for Incomplete Laceration of the Perineum (Macphatter) . . 342 

255. Flap-splitting for Gomplete Laceration of the Perineum (Macphatter) ... 343 

256. Introduction of Sutures in Flap-splitting Operation (Baldy) 344 

257. Inversion of the Uterus (Jeancon) 346 

258. Complete Inversion of the Uterus (Biot) • 347 

259. Thomas's Operation for Replacement of an Inverted Uterus (Thomas) . . . 350 

260. Sarcoma of the Body of the Uterus (Baldy) 359 

261. Epithelioma of the Cervix Uteri (Baldy) 364 

262. Simple Amputation of the Cervix, stitches w siYw (Baldy) . 371 

263. Simple Amputation of t\\Q Cervix, stitches tied (Baldy) 372 

AVedge-shaped Amputation of the Cervix, sutures in place (Baldy) 373 



264. 



LIST OF ILLUSTRATIONS. xix 

FIG. PAGE 

265. Wedge-shaped Amputation of the Cervix Uteri, sutures tied (Baldy) .... 373 

266. Profile of the Wedge-shaped Amputation of the Cervix Uteri, sutures in 

place (Baldy) 374 

267. Profile of the Wedge-shaped Amputation of the Cervix Uteri, sutures ready 

to tie (Baldy) 375 

268. Malignant Adenoma of Uterine Mucous Membrane, beginning glandular 

epithelium (Ruge and Veit) 382 

269. Carcinoma of the Body of the Uterus (Baldy) 383 

270. Vaginal Hysterectomy : opening the posterior cul-de-sac (Auvard) 390 

271. Section of an Ovary, showing its surface covered with papillomata (Doran) . 394 

272. Papillomatous Cystic Tumor of the Ovary (Doran) 394 

273. Papillomatous Disease of the Broad Ligament (Doran) 395 

274. Sarcoma of both Ovaries {Annals of Gynecology) 396 

275. Small Muriform Polyp of the Cervix (Pozzi) 398 

276. Intra-uterine Fibroid Polyp (Baldy, from photograph in possession of Dr. 

B. H. Baer) 399 

277. Uterine Fibro-myoma, microscopic view (Pozzi) 400 

278. Submucous Uterine Fibroma (Baldy) 401 

279. Submucous Fibroid Tumor of the Uterus (Baldy) 401 

280. Large Fibrous Interstitial Tumor of the Uterus (Sims) 402 

281. Subperitoneal Pediculated Fibroid of the Uterus (Labbe) 402 

282. Interstitial Fibroid of the Uterus (Farre) 403 

283. Calcareous Degeneration of Fibroma (Baldy, from specimen in possession of 

Dr. C. B. Penrose) 403 

284. Pediculated Fibroid with Abdominal Evolution (Pozzi) 404 

285. Enlarged Blood-vessels on the Surface of a Fibroid (Baldy) 405 

286. (Edematous Submucous Fibroid (Carswell) 408 

287. Removal of Fibroma by Morcellation (P6an) 413 

288. Subperitoneal Nodular Fibroid Tumor of the Uterus (Baldy) 414 

289. Method of Removal of Subserous Uterine Fibroid (Baldy) 415 

290. Enucleation of an Interstitial Myoma (Pozzi) 416 

291. Knot of Rubber Ligature secured by a Silk Ligature (Pryor) 417 

292. Serre-noeud for Hysterectomy 417 

293. Relation of the Ureters and Uterine Arteries to the Cervix (Pozzi) ..... 419 

294. Deschamp's Needles 421 

295. Application of Ligatures in Ablation of Fibroid Uterus (Pryor) 421 

296. Intra-ligamentous Fibroma (Pozzi) 425 

297. Suture of the Peritoneum and Fibrous Tissue left after the Detachment of a 

Firm Adhesion from the Intestine (Pozzi) 428 

298. Normal Fallopian Tube, microscopic section (Wyder) 449 

299. Hydrosalpinx (Baldy, from photograph in possession of Dr. Brokaw) . . . 450 

300. Hydrosalpinx [Annals of Gynecology) , 451 

301. Chronic Interstitial Salpingitis and Ovaritis, with thickened broad ligament — 

so-called cellulitis (Baldy) 453 

302. Fallopian Tube and Ovary, showing adhesions (Baldy) 454 

303. Double Pyosalpinx and Diseased Uterus (Baldy) 455 

304. Pyosalpinx and Ovarian Abscess [Arch, fur Gynecologie) 456 

305. Broad thin Band of Adhesions (spider-web) hanging from an Adherent Ovary 

and Fallopian Tube (Baldy) 459 

306. Ovary Displaced and bound Down in the Cul-de-sac by Adhesions 460 

307. Drainage of Pelvic Abscess from the Vagina (Baldy) 498 

308. Abscess-sacs opening into the Bowel : opening obliquely above and below 

the level of the sac (Baldy) 499 



XX LIST OF ILLUSTBATIONS, 

FIG. PAGE 

309. Stricture of the Fallopian Tube: the ovary enlarged by chronic ovaritis 

(Baldy) . 501 

310. Showing Multiple Abscess-cavities in a case of Pyosalpinx, demonstrating 

the uselessness of the treatment by tapping and drainage (Baldy) . . . 501 

311. Ligation by Figure-of-eight Ligature of the Fallopian Tube and Ovary 

(Baldy) 508 

312. Stump after removing Ovary, showing double ligation of ovarian artery 

(Baldy) 511 

313. Pyosalpinx from a Woman over Sixty Years of Age (Baldy) 515 

314. Gravid Fallopian Tube at the Tenth Week, showing complete occlusion of 

the ostium (Bland Sutton) 521 

315. Diagrammatic Section of Fallopian Tube, representing the two directions of 

rupture in tubal pregnancy. A, into the peritoneal cavity (Tait) . . . 522 

316. Ibid. B, between the folds of the broad ligament (Tait) 522 

317. Transverse Section of the Pelvis of a Woman, with an Embryo and Placenta 

of the Fourth Month of Gestation occupying the Right Broad Ligament 
(Hart) 524 

318. Tubo-uterine Pregnancy (Bland Sutton) 525 

319. Diagrammatic Representation of Interstitial Tubal Pregnancy at the time of 

Rupture (Tait) c 526 

320. Pregnant Fallopian Tube Laid Open, showing fetus killed by hemorrhage 

into its membranes, but without the escape of the fetus from the tube 
(Tuttle and Cragin) 527 

321. Apoplectic Ovum, or Tubal Mole (natural size) (Bland Sutton) 528 

322. Decidua expelled from the Uterus in a case of Ectopic Gestation (Tuttle and 

Cragin) 533 

323. Decidua i?i situ : fibroid uterus removed at the time of operation for ruptured 

ectopic gestation (Tuttle and Cragin) 534 

324. Photomicrograph of a Section of Decidua in a case of Ectopic Gestation, 

showing the large decidual cells (Tuttle and Cragin) 535 

325. Photomicrograph of Chorionic Villi, found in the tube of a case of ectopic 

gestation (Tuttle and Cragin) 538 

326. Tubal Rupture in the case of an Ectopic Gestation (Tuttle and Cragin) . . 540 

327. Horizontal Section of the Abdomen immediately above the Crests of the Ilii 

(Savage) 544 

328. Uterus, Ovary, Fallopian Tube, Broad Ligament, and its Contents (Savage) . 546 

329. Section of Ovary 547 

330. Typical Corpus Luteum, fifteenth day from the beginning of menstruation 

(Leopold) 547 

331. Freshly-ruptured Follicle, twenty days after the beginning of the last 

menstruation (Leopold) 547 

332. Transverse Section of the Fallopian Tube of a Macaque Monkey (Bland 

Sutton) 548 

333. Recess of the Tubal Mucous Membrane of the Panolian Deer (Bland Sutton) , 549 

334. Transverse Section of the human Fallopian Tube (Schenck) 550 

335. Diagram of the Structures in and adjacent to the Broad Ligament (Doran) . 558 

336. Broad-ligament Cyst, Fallopian Tube, and Ovary (Baldy) 559 

337. Cyst of the Organ of Morgagni (Baldy) 560 

338. Large Ovarian Cyst, weighing 149 pounds [N. Y. Med. Jour.) 562 

339. Proligerous Glandular Ovary and Cyst of areolar appearance (Pozzi) .... 563 

340. Multilocular or Glandular Cystoma (Montgomery) 564 

341. Portion of an Ovarian Adenoma, showing the varieties of loculi (Bland 

Sutton) ; 565 



LIST OF ILLUSTRATIONS. xxi 

FIG. PAGE 

342. Calcified Corpus Luteum (Williams) 566 

343. Dermoid Cyst containing long red hair, removed from a light-haired woman 

aged 44 years (Montgomery) 567 

344. Calcified Fibroma of the Ovary (Williams) 569 

345. Showing the Structure of Calcified Fibromata (Williams) 570 

346. Distension of the Abdomen by an Ovarian Tumor (Montgomery) 582 

347. Fatty Abdominal Wall simulating an Ovarian Cyst (Baldy, from photograph 

in possession of Dr. Eobert Hamill) 589 

348. Triple Interlocking Ligature : the threads inserted (Greig Smith) 604 

349. Triple Interlocking Ligature : the threads interlocked ready for tying (Greig 

Smith) 604 

350. Triple Interlocking Ligature tied (Greig Smith) 604 

351. Caruncle attached to the Posterior Lip of the Urethral Orifice (Kelly) . . . 617 

352. Caruncle occluding the Urethral Orifice (Kelly) 617 

353. Urethral Diverticulum containing pus and residual urine (Kelly) 619 

354. Pelvic Portion of the Ureter viewed from below (Kelly) 654 

355. Pelvic Portion of the Ureter viewed from above (Kelly) 655 

356. Course of the Ureters marked on the Abdomen (Kelly) 656 

357. Kelly's Ureteral Sounds 857 

358. Kelly's Ureteral Catheters 657 

359. Catheterization of both Ureters (Kelly) 658 

360. Sutures in place for the Eepair of Ventral Hernia (Baldy) 681 



LIST OF PLATES. 



iiece. 



20 



22 



26 

28 
30 

44 



PLATE OPPOSITE PAGE 

I.— Fig. 1. Median Section of the Pelvis ] Front' <i 

Fig. 2. Dissection of the Perineum j 
II. — Fig. 1. Dorsal Position for Pelvic Examination : faulty (Baldy) | 
Fig. 2. Dorsal Position for Pelvic Examination : faulty (Baldy) J 
III. — Fig. 1. Dorsal Position for Pelvic Examination : correct (Baldy) | 
Fig. 2. Knee-chest Position (Baldy). J 

IV. — Fig. 1. Left Lateral or Sims's Position : front view (Baldy) ] ^^ 

Fig. 2. Left Lateral or Sims's Position : back view (Baldy) j 
V. — Patient in Trendelenberg's Position on Krug's Frame : side view (Baldy) . 
VI. — Patient in Trendelenberg's Position on Krug's Frame : front view (Baldy). 

VII. — Bimanual Palpation of the Pelvis (By ford j 

VIII. — Fig. 1. Exposure of the Cervix through Sims's Speculum (Byford) | 
Fig. 2. Simon's Position, showing use of Retractors (Byford). i 

IX. — Operating-room of the Gynecean Hospital prepared for an operation 

(Baldy) 60 

X. — Leg-holder applied with the patient in the Dorsal Position (Baldy) . . 72 
XL — Microscopic View of Menstrual Fluid at different periods of Menstru- 
ation (Pouchet) , 82 

XII. — Pseudo-external Bilateral Hermaphrodism (Krug) , 132 

XIII. — Hypertrophy of the Nymphse, or Hottentot Apron (Billroth and Leuke) . 164 
XIV. — Fig. 1. Hypertrophy of Right Labium Majus (Baldy). ^ 

Fig. 2. Hypertrophy of Right Labium after two weeks' treatment >- . 166 
(Baldy). J 

XV. — Hypertrophy of the Skin about the Vulva and Anus (Baldy) 168 

XVI. — Distended Vulvo-vaginal Gland (Byford) 172 

XVII. — Removal of Carcinoma of the Uterus by the use of the Galvano-cautery 

after the Method of Byrne (Dickinson) . 378 

XVIII. — Fig. 1. Vaginal Hysterectomy with Clamps. Single-clamp Operation ^ 
(Baldy). ' 

Fig. 2. Vaginal Hysterectomy with Clamps, 
tion : first step (Baldy). 
XIX. — Fig. 3. Vaginal Hysterectomy with Clamps, 
tion : second step (Baldy). 
Fig. 4. Vaginal Hysterectomy with Clamps, 
tion : third and final step (Baldy). 
XX. — Fig. 1. Vaginal Hysterectomy with Ligature 

Fig. 2. Vaginal Hysterectomy with Ligature : second step (Baldy) J 
XXI. — Fig. 3. Vaginal Hysterectomy with Ligature : third step (Baldy). "j 
Fig. 4. Vaginal Hysterectomy with Ligature : fourth and final step V . 
(Baldy). J 

XXII. — Extra-peritoneal Treatment of the Stump following Hysterectomy (Baldy). 
XXIII. — Fig. 1. Supra-vaginal Amputation of the Uterus: first step (Baldy). | 
Fig. 2. Supra-vaginal Amputation of the Uterus : second step (Baldy) j 



Multiple-clamp Opera- 
Multiple-clamp Opera- 
Multiple-clamp Opera- 
first step (Baldy). ] 



!^. 386 

I 
J 



388 

392 

394 

416 
418 



XXlll 



xxiv LIST OF PLATES. 

PLATE OPPOSITE PAGE 

XXIV.— Fig. 3. Supra- vaginal Amputation of the Uterus : third step (Baldy) \ 

Fig. 4. Supra- vaginal Amputation of the Uterus : fourth and final V . 420 
step (Baldy). J 

XXV. — Fig. 1. Arterial Blood-supply of the Uterus and Adnexa (Hart) | ^^^ 

Fig. 2. Venous Blood-supply of the Uterus (Hart). J 

XXVI. — Fig. 1. Total Abdominal Hysterectomy : first step (Baldy) 424 

XXVII.— Fig. 2. Total Abdominal Hysterectomy : second step (Baldy) | .gg 

Fig. 3. Total Abdominal Hysterectomy : third step (Baldy) J * * ' 
XXVIII. — Fig. 4. Total Abdominal Hysterectomy : vaginal opening closed by 

sutures (Baldy). (^ ^ 428 

Fig. 5. Total Abdominal Hysterectomy : vaginal opening closed by 
gauze packing (Baldy) 

XXIX. — Intra-ligamentous Fibroid : front and back views (Baldy) 480 

XXX. — Pyosalpinx and Ovarian Abscess (Baldy) 458 

XXXI. — Combined Ectopic and Intra-uterine Gestation (Tuttle and Cragin) . 518 
XXXII. — Full-term Fetus developed between the Folds of the Right Broad 

Ligament (Tuttle and Cragin) 522 

XXXIII. — Tubal Abortion : membranes protruding from the fimbriated extrem- 
ity of the Fallopian Tube (Tuttle and Cragin) 526 

XXXIV. — Tubal Abortion : placenta and Fetus protruding from the fimbriated 

extremity of the Fallopian Tube (Tuttle and Cragin) 528 

XXXV. — Intra-ligamentary Broad-ligament Cyst (Baldy) 558 

XXXVI. — Dermoid Cyst laid open and showing the various contained structures 

(Baldy) 568 

XXXVII. — Course of the Ureters and Pelvic Blood-vessels (Kelly) 656 



AN AMERICAN 

TEXT-BOOK OF GYNECOLOGY. 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 



In making an examination for disease of the female pelvic 
organs, the first thing for a physician to do is to acquire the confi- 
dence of the patient. The next thing is to possess an adequate 
knowledge of all known physiological and pathological conditions 
of these organs. An untidy office, a dirty hand, a careless manner, 
and a rough demeanor are as inimical to his success as a lack of 
knowledge and training in gynecology. The fear of the patient 
that she may become infected by filth, hurt by manipulation, or 
neglected through carelessness is often sufficient to deter her from 
undergoing treatment that is, under the most favorable circum- 
stances, a distasteful and onerous undertaking. He should remem- 
ber that the patient comes prepared to sacrifice all preconceived 
notions of modesty to his dictum, and does it with the full belief 
that he possesses the refinement of a gentleman and the acquire- 
ments of a scholar. 

He must not be impatient if she commences talking first of other 
parts of the body, avoids complete explanations of certain symp- 
toms, or is a little dilatory in submitting to the necessary examina- 
tions. On the other hand, he should never abate in his deference 
to a woman who, having once submitted to gynecological treatment, 
conducts herself toward him with that familiarity and trustfulness 
which the sacredness and dignity of his calling inspire. 

If she chooses to talk, it is well to listen attentively to the recital 
of her ailments until satisfied that they are of pelvic origin, when 
the physician may commence by appropriate questions to obtain a 
systematic description of her case. The data should be entered in 



18 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

a case-book in somewhat the following order: Name; age; whether 
married or not, and if so, whether more than once ; the number of 
confinements, with dates of first and last, and number and dates of 
abortions ; her occupation and habits, whether sedentary or active ; 
age of first menstruation, and how regular since then ; whether 
menstruation is painful or not; when the pain commences and 
stops, and where it is felt and what its character ; the length of 
time the flow lasts, whether profuse and clotted, or scanty, or pro- 
longed by recurrence after cessation for a few hours or days ; 
amount and character of discharge from vagina between the men- 
strual periods ; the condition of nutrition as seen by the appear- 
ance of the tongue, conjunctiva, and skin, and the state of the 
nervous system. 

Having obtained these facts, and others that may be acquired 
during the questioning, he will have a foundation upon which to 
construct an accurate diagnosis. The patient may be allowed to 
relate her special symptoms, or he may inquire for the various 
ones that accompany the disorders under consideration, or may ask 
for special symptoms of whatever disease the knowledge already 
acquired leads him to expect. 

He should always differentiate carefully between conditions 
which are of such gravity and long standing as to call for an exam- 
ination, and those which are temporary and may be relieved by 
general treatment. 

The functions of the kidneys, bladder, bowels, and rectum should 
be inquired into, as well as the effect of exercise or quiet upon her 
symptoms. A qualitative and quantitative analysis of the urine 
and an examination of the heart should be made in very fleshy or 
anemic patients, and also in those presenting symptoms referable 
to the abdomen and chest. 

Preparations for an Examination. 

Although the examination in most cases can be made without 
preparation of the patient and at the first interview, yet when there 
is any difficulty in arriving at an accurate diagnosis it is well to 
have her return upon another occasion properly prepared. Such 
preparation should consist in mild purgation upon the day previous, 
and a soapsuds enema on the morning of the examination. The 
diet on the same day should be light, and the bladder evacuated 
immediately before the visit. 



EXAMINATION OF THE FEMALE PELVIC ORGANS, 19 

When the examination is made at the patient's house, a sofa 
without arms may be drawn near a window, with stools placed at 
the end for the feet, or a table may be used with chairs for the feet. 

Fig. 1. 




The Allison Gynecological Table, arranged for Dorsal Position. 

When more convenient, the patient may sit on a pillow placed at 
the edge of a bed and lie back with the feet on chairs placed two 
feet apart. The corset and waist-bands should be loosened. 

Fig. 2. 




The Allison Gynecological Table, arranged for the Left Lateral Position. 

At the office the physician should be provided with a gyneco- 
logical table or a chair of simple construction that allows of elevat- 
ing or depressing the shoulders or that can be made perfectly flat. 
Stirrups should be attached, so arranged that the feet can be ele- 



20 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



vated, depressed, or separated to any required extent, and held near 
the body or some distance away. 



Fig. 3. 




The Indianapolis Gynecological Chair, arranged for Dorsal and Lateral Positions. 

The end of the chair or table should be toward and near a window. 
Between it and the window, and at the right hand of the operator 
as he sits facing the chair, should be placed a cabinet or stand with 



Fig. 4. 




Gynecological Cabinet. 



drawers for holding instruments, medicine, and appliances. A sta- 
tionary washstand should be near. By thus having everything con- 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 21 

venient, one works easily and rapidly and saves time to himself and 
trouble to the patient. 

Fig. 5. 




Arrangement for Office Examination and Treatment. 

A sheet should always be at hand to throw over the patient as 
she lies down. 

Position of Patient. 

For ordinary pelvic examinations the patient should be put on 
her back, with the hips at the edge of the chair or table, facing the 
window, and the feet supported in the stirrups on a level with her 
hips, far enough apart to allow ample space between them for the 
physician to work, and far enough from the patient's body for her 
comfort. Generally the head and shoulders should be slightly 
higher than the. hips. In special instances we may elevate the 
shoulders and feet in order to secure greater abdominal relaxation. 
This is called the dorsal position. It is the best position for the 



22 ^^y AMERICAN TEXT-BOOK OF GYNECOLOGY, 

digital and bimanual examinations, and is often employed for 
ordinary treatment on account of its convenience. 

A digital examination may be made in the Left Lateral or Sims' 
position. The patient is placed upon her left side with the hips at 
the left-hand corner of the table, and both knees drawn up as far 
toward the chest as possible. The left arm should be drawn back 
behind her, and the right or upper knee drawn a little farther up 
and over the left until it almost touches the table, in order that the 
patient may be tipped on her left breast. Care must be taken to 
keep the knees well flexed. It is better to have the foot of the 
table a little higher than the head. 

This position has the disadvantage that the upper pelvic organs 
are not as easily reached as in the dorsal, and that it must be changed 
to the dorsal position for the bimanual examination. For inspection 
of the vaginal fornices, tamponment of the vagina, and operations 
upon the cervix and anterior vaginal wall, it is in this country and 
England the favorite position. 

The Knee-chest position requires that the patient kneel near the 
edge of the table, and, with arms thrown back and head turned to 
one side, allow the chest to sink down on the table just in front of 
the knees. The thighs are flexed on the abdomen. The chest is 
lower than the pelvis, and when air is allowed to enter the vagina 
the uterus sinks away from the vaginal entrance. This peculiarity 
is shared by the lateral position. For altering the position of the 
pelvic organs and for vaginal tamponment this position is useful, 
but it is not desirable for ordinary examinations. 

The Trendelenburg position is obtained by placing the patient 
on her back and raising the lower end of the table, thus elevating 
the pelvis and thighs and allowing the legs to fall over the edge. 
Its chief advantage is for operations upon the pelvic organs by 
abdominal section. The abdominal viscera recede from the pelvis, 
and leave the pelvic peritoneal cavity open to inspection through 
the abdominal incision. It is not often employed for examinations 
per vaginam. The accompanying cuts illustrate this position as 
obtained by the use of Florian Krug's frame, which can be fastened 
to any table. 

The Upright position gives information as to the position of the 
pelvic organs while the patient is up and about her duties, and is 
chiefly useful in determining the extent of displacements. In this 
position the patient stands against some supporting object with the 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 23 

feet separated, while the physician kneels on one knee in front of 
her. 

Methods of Examination. 

There are three methods of examination : the ocular, the manual 
or digital, and the instrumental. 

Ocular Examination. — If the symptoms point to a disease of the 
vulva or vagina, the patient is placed in the dorsal position, covered 
with a sheet, the skirts pushed up over and beyond the knees, and 
the sheet pushed back between the limbs over the mons Veneris, so 
as to expose the vulva and perineum. The external parts and 
vaginal entrance are then inspected, and the finger introduced as 
far into the vagina as necessary. 

Digital Examination per Vaginam, — For this examination the 
best position is the dorsal. If the symptoms point to intrapelvic 
disease, it is best not to expose the patient at first, but pass the 
partly-closed hand under the sheet along the inside of the thigh 
until the dorsal surfaces of the fingers gently touch the perineum 
or vulva. The position of the labia majora will be immediately 
recognized and any abnormal condition detected. The dorsal sur- 
face of the index finger is gently pushed between them until 
arrested in the vaginal entrance. The finger is then extended, 
and the finger-end glides over the perineum into the vagina. 
Any peculiarity of the hymen, obstruction from a vaginal tumor 
or prolapsed organs, or gaping of the parts from relaxation or 
laceration will be forced upon the attention, either by the difficulty 
or the unusual ease of the manoeuvre. When there is much devia- 
tion from the normal, the parts may be exposed to view at once, 
otherwise the ocular inspection and external manipulation are better 
left until the internal examination has been made. 

After the finger has entered the vagina the posterior wall, or 
rectum which lies under it, will attract attention if abnormal. If 
not, the finger is turned, palmar surface upward, and slight pressure 
against the anterior vaginal wall is made to detect enlargement, dis- 
placement, or tenderness of the urethra and bladder or organs above 
them. 

Having thus gone over the parts about the vaginal entrance, the 
objective point should always be the cervix uteri. It should be 
found from two and a half to three inches from the pubic arch, so 
that when the finger touches the cervix and is raised up against the 



24 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



anterior vaginal wall, the subpubic ligament will press against the 
finger between the second and third joints. The finger-end is swept 
around the cervix to see if the fornices are diseased or encroached 
upon by surrounding abnormal tissue. Very often one lateral 



Fig. 6. 




Normal Position of the Uterus. 



fornix is narrower than the other, and by pressing straight outward 
laterally the distance of the pelvic wall will be found to be less on 
that side, and lateral displacement detected. 

The size, shape, and consistency of the cervix and the position 
and shape of the external os — in fact, all changes except in color — 
are discovered in this way, and the diagnosis usually made before 
the speculum is used. The finger-end should press well up in 
front, behind, and to the sides of the cervix, in search of an ante- 
or retroverted or flexed fundus, adherent ovary or pelvic exudate. 
By pressing well back and laterally we can sometimes catch an 
enlarged or prolapsed ovary against the pelvic walls. The right 
hand should be used for palpating the right side of the pelvis, and 
the left hand for the left side. 

Vaginal palpation of the ureters is easily executed in the dorsal 
position, and should always be practised. They are much more 
easily felt than might be supposed, because they are situated at the 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 25 

dividing-line between the soft, elastic parametric connective tissue 
and the firmer peripheral fatty connective tissue, at the lateral and 
front parts of the pelvis. The finger-end, pressed very gently up- 
ward in front of the cervix and drawn toward the pubes, feels, about 
half an inch in front of the cervix, the posterior edge or base of the 
trigone of the bladder, and then comes upon the firmer part of the 
anterior vaginal wall under the trigone. By repeating this forward 
and upward hooking motion of the finger-end, getting a little more to 
one side each time, the same cord-like edge of the firmer tissue repre- 
senting the ureter can be traced laterally and backward toward the 
sacro-iliac synchondrosis. During the earlier months of pregnancy, 
and in the presence of disease of the ureters, they are easily traced as 
large, somewhat tense cords, backward and outward to the pelvic w^alls. 

Fig. 7. 
/•"" — . 

.Vertebra 

._ Sacro-ut Lig 

, .^. - Cervix 

Pelvic brirrv 

...... Ureters 

'^" ' -^- -Neck of bladder 

Symphysis 

Direction of the Ureters. 

Two fingers may be used in the vaginal examination when it is 
desirable to reach further than possible with one. One finger is, 
however, generally to be preferred, because the touch is freer and 
more delicate and the inconvenience less to the patient. 

By hooking two fingers backward toward the coccyx, and then 
strongly outward toward the anus, the anterior wall of the rectum 
may be everted, and its condition, as well as that of the anal rim, be 
revealed to the eye. . The manoeuvre is somewhat painful, and not 
always well tolerated by the patient. The finger and thumb of the 
other hand may with advantage push the tissues behind the anus 
backward, so as to increase the anal distension. 

Digital Examination per Rectum. — In virgins with sensitive 
hymen or small vaginae, or other patients in whom the posterior 
pelvic wall cannot be reached, or in whom conditions in the pos- 
terior half of the pelvis cannot be diagnosed through the vagina, 
rectal indagation gives valuable information. 




26 



AJS" AMERICAN TEXT-BOOK OF GYNECOLOGY. 



As the rectum is dry and sensitive, the forefinger should be 
abundantly smeared with vaseline or some other unirritating fat, 

Fig. 8. 




i0^ 



Digital Eversion of the Rectum. 

and introduced, palmar surface down, in a forward direction until 
the finger-end has passed over the edge of the levator ani (rectal 
promontory), and then flexed a little until the whole finger is 
introduced. Then it should be straightened and slowly rotated 

Fig. 9. 




Palpation of the Coccyx. 

until the palmar surface can be used to palpate the interior w^all. 
Before rotating it is well to touch the coccyx, or even grasp it be- 
tween the finger wdthin and the thumb without. Fracture, anky- 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 27 



losis, unusual mobility, abnormal sensitiveness, or dislocation can 
be detected. 

As soon as, or even before, the finger is rotated, the cervix, or, 
if there be retroflexion, the fundus uteri, will usually be detected 
within easier reach than per vaginam. The finger is then 23ressed 
on under the retroflexed or retroverted fundus, and readily detects 
an ovary or tube in the cul-de-sac of Douglas or any induration at 
the uterine horns. The retroverted fundus can be pressed upward, 
and any unusual resistance or bands of adhesions recognized. 
Appendages or tumors adherent to the lateral and posterior walls 
of the pelvis are easily felt. The connective-tissue fibres running 
from the cervix to the pelvic walls usually shut off the upper part 
of the pelvis from observation. In order to reach these higher 
parts the finger-end is pushed along against the sacrum, until it 
passes through a constricted part of the gut and emerges up behind 
the uterus, and between and over the sacro-uterine ligaments. It 
then has access to the lower abdominal cavity and can palpate the 
parts with distinctness. Usually, however, the anus is too sensitive 
or the finger too short to allow of a satisfactory exploration of this 

Fig. 10. 




Rectal Palpation of the Uterus drawn down by a Vulsellum Forceps. 

kind, and two fingers with the aid of anesthesia will be required. 
The half or whole hand can be passed into the rectum and a com- 
plete intrapelvic exploration made. This, however, is apt to injure 
the sphincter ani and rectum, and is generally unnecessary, for the 



28 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



bimanual examination with two fingers in the rectum gives us the 
same information without it. 

An accurate knowledge of anatomy, and a little practice, will 
enable us to palpate and recognize the pyriformis muscle and the 
sacral plexus of nerves lying upon it, the small sacro-sciatic liga- 
ment, the greater sciatic foramen, the various pelvic arteries, etc. 

With the index finger in the rectum and the thumb in the vagina 
the cervix, or even the retroverted uterus, may be grasped and its 
size, mobility, and i^elations determined. 

The fundus uteri and adjacent tissues may be rendered more 
accessible to the rectal finger by drawing the cervix to the vaginal 
entrance with a vulsellum forceps. 

The Bimanual Examination. 

In order to complete our information with regard to the pelvic 
organs it is necessary to make use of the bimanual examination. 
To do this we first inform ourselves of the position of the cervix, 
etc., by ordinary vaginal indagation, after which the other hand, 

Fig. 11. 




Bimanual Palpation of the Uterus. 



previously placed over the pubes, presses gently, but with increasing 
firmness, upon the abdominal walls, sinking the finger-tips a little 



^ 







EXAMINATION OF THE FEMALE PELVIC ORGANS. 29 

deeper with each inspiration of the patient, until the uterus is felt 
to descend upon the vaginal finger. Thus the uterus is brought 
down until its anterior and lateral surfaces can be easily palpated 
through the anterior vaginal wall. By a series of gentle pushes 
from above and below the position, mobility, size, and shape of the 
uterus can be ascertained. Great gentleness must be observed not 
to hurt the patient nor to displace the organ before its position is 
determined. In case the fundus is not felt, the outside finger should 
be pressed into the abdominal walls a little higher up. When the 
abdominal walls are lax or the patient anesthetized, they can be 
depressed until the sacral promontory is felt. Then the fingers are 
brought downward toward the pubes until they are felt by the vaginal 
finger to touch and move the uterus. Under an anesthetic the retro- 
verted uterus can be picked up between the fingers bimanually and 
replaced, or if adherent its mobility tested. 

The uterus can be retroverted by hooking the cervix forward by 
the vaginal finger, and sinking the external fingers over the pubes 
and pressing toward the sacral promontory, and thus the posterior 
surface brought within reach. 

By pressing well down beside the uterus until the fingers of both 
hands touch with only the abdominal wall^ between, we may palpate 
the ovaries and tubes. If the ovaries are not easily recognized, the 
fingers of the two hands should be kept in contact and brought 
toward the pubes and Poupart's ligament, alongside the anteverted 
uterus, from the cervix toward the fundus. The first decided infor- 
mation is given by the sudden slipping of the ovarian ligament 
between the finger-ends, like a tense cord stretched across the field. 
By repeating this manoeuvre a little further to the side, we come 
against the ovary, which if small may merely feel like a fusiform 
enlargement of this cord. The ureter may give a sensation similar 
to the ovarian ligament, but it feels less tense and is easily traced to 
the side of the pelvis by the vaginal finger, and thus differentiated. 
The round ligament feels like a relaxed cord, and is only felt indef- 
initely. The normal Fallopian tube gives only a very indefinite 
sensation, as of a fold of membrane. When enlarged and occluded 
it usually curves backward over the ovary, and feels somewhat like 
a small fusiform or club-shaped tumor tapering toward the horn of 
the uterus. Extensive adhesions usually cause a matting together 
of the appendages in a roundish or irregular-shaped mass, but little 
movable itself, and partially fixing the uterus. 



30 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



With one or two fingers in the rectum the external (abdominal) 
and vaginal fingers may be approximated behind the uterus, and 
the condition of the posterior and upper parts of the pelvic cavity 
quite accurately ascertained. 

Fig. 12. 




Bimanual Rectal Palpation of the Pelvis. 

With a finger in the rectum and the thumb in the vagina grasp- 
ing the cervix, while the fingers and thumb of the other hand grasp 
the- fundus through the abdominal walls, the consistency, flexibility, 
size, mobility, and relations of the uterus can be appreciated with 
a surprising degree of ease. The displaced uterus can be grasped 
and replaced in this way. 

In order to become an expert diagnostician the gynecologist 
should accustom himself to use either hand in the vagina or over 
the abdomen, that he may be able to reach both sides of the pelvis. 

The bimanual examination of the uterus is of the utmost import- 
ance in the diagnosis of pelvic tumors. Ovarian tumors of mode- 
rate size are often entirely overlooked when they lie over and behind 
the uterus, because they are not within reach of the vaginal finger. 
When, however, the abdominal walls are pressed down into the 
pelvis, not only is the tumor discovered, but its size, consistency. 



bc 



Ei 

JO 

o' 





<1 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 31 

mobility, and the length of its pedicle are often recognizable. Tu- 
mors of the uterus can be mapped out in this way and their size 
and relations to the organ determined. 

Digital and Bimanual Examination in the Lateral Position. — 
Similar examinations may be made in the left lateral position with 

Fig. 13. 




Bimanual Recto-vaginal Palpation of the Uterus. 

the left hand in the vagina or rectum and the right hand over the 
abdomen, but hardly as satisfactorily as in the dorsal position. 
However, it gives one a better comprehension of the mobility and 
relationship of the organs to examine in both positions and compare 
results. 

Anesthesia. 

In many cases, even after a thorough evacuation of the bowels, 
the tension of the abdominal walls, the sensitiveness of the organs, 
or the complications in the pathological conditions render a satis- 
factory examination impossible. In such cases the administration 
of an anesthetic not only renders all of the methods described 
available, but the relaxation of the tissues enables us to employ 



32 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

them without force and without fear of causing that feeling of sore- 
ness and discomfort that sometimes follows a thorough examina- 
tion without the anesthesia. When there is the slightest doubt as 
to the pathological condition, the patient should always be anes- 
thetized for the examination. 

Examination of the Vaginal Entrance. 

An ocular examination of the vaginal entrance will reveal the 
condition of the superficies, but will be incomplete unless aided by 
the educated touch. If a laceration is mostly external, its extent 
is much better appreciated if the finger be introduced into the anus 
and the thickness of the perineal body palpated between the finger, 
and thumb. The scar-tissue may be blanched and made plainly 
visible by pulling out the tissues with the finger in the anus, so 
as to stretch the perineal body. If the fourchette be intact, the 
extent of internal deficiency due to laceration may be measured by 
pressing the finger down along the pubic rami within the vulvo- 
vaginal entrance. Normally, the levator vaginae stretches around 
the vaginal entrance, so as to prevent palpation of the pubic ramus 
except by quite firm i^ressure. When the fibres of this muscle are 
torn, the anterior sulci beside the urethra are widened and the bony 
surfaces easily felt. The vaginal entrance, instead of being ovoid 
or roundish, is bounded posteriorly by the V-shaped edge of the 
levator ani, with the rectum passing over it filling the angle and 
leaving a sulcus on either side. When the transversus perinei is 
torn, the finger readily traces the bony surfaces of the pubic rami 
down to a level with the anus on the side of the tear. When the 
sphincter is torn, the anterior edge of the anus is thin and cicatricial, 
and the dark-red edges of the rectal mucous membrane are visible^ 
often giving an ulcerated appearance to the novice. 

Instrumental Examination. 

The Uterine Sound. — Various forms of uterine sounds have been 
devised. The most serviceable ones are Simpson's and Sims'. 
They are about 30 cm. long, and from 2 to 3 mm. in diameter, 
with a slightly enlarged bulbous end. The end toward the handle 
is somewhat thicker. Simpson's sound, formerly stiff, is now made 
of a somewhat flexible metal, and has a mark indicating the normal 
length of the uterine cavity (2i inches, or 7 cm.) ; Sims' sound is 
a trifle lighter and much more flexible than Simpson's. They 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 33 

should be made entirely of metal. Jenks' spiral sound and Thomas's 
whalebone or hard-rubber probe are useful forms, because they 
adapt themselves to the curve of the uterine canal. On account 
of their elasticity they do not retain its curve. Uterine probes 
resemble the sound in shape, but are more delicate, and are useful 
in exploring a distorted uterine cavity. 

Fig. 14. 




Simpson's Uterinti Sound. 
Fig. 15. 




Sims' Uterine Sound. 
Fig. 16. 







Jenks' Uterine Sound. 
Fig. 17. 




Thomas's Hard-rubber Probe. 



To Introduce the Sound, the cervix should be located with the 
index finger, and the sound, bent about seven centimetres from its 
point at an angle of about forty-five degrees, introduced along the 
palmar surface until the bulbous end passes into the cervical canal. 
By depressing the handle and, if necessary, drawing the cervix 
slightly forward either with the finger, the sound, or a tenaculum, 
the instrument easily passes to the fundus. No force must be used, 
but the curve of the sound changed again and again, if necessary, 
until it passes easily. By giving it a sharper curve with a coun- 
ter-curve near the handle we often succeed better in making it pass 
a more acute flexure. 

The dio^ital or bimanual examination will often enable us to 
determine what the angle or curvature of the sound must be. A 
narrowness of the internal os, due to uterine flexion or spasmodic 

3 



34 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



contraction, sometimes interferes with the passage of the sound and 
may render it painful. In such cases much force should not be 
used, but the attempt postponed until an examination by the 
speculum is made. 

Fig. 18. 




Curves of the Uterine Sound to Facilitate Introduction. 

The Uses of the sound consist in ascertaining the patency of the 
uterine canal, its direction, length, size, and sensitiveness. In con- 
nection with the abdominal palpation we can also determine in what 
part of the uterus the enlargement or tumor is located. The mobility 
of the uterus and its connection with the pelvic organs, or its inde- 
pendence of them, can thus be more accurately determined than by 
the ordinary bimanual examination alone. 

The Dangers in the use of the sound are the introduction of 
septic matter into the uterus, the lighting up of an old endometritis 
or pelvic inflammation, and the perforation of the uterine walls. 

It is better, when practicable, to use the sound through the specu- 
lum after the vaginal fornices and cervix have been wiped out dry 
with absorbent cotton, and then swabbed out with a 5 per cent, 
solution of carbolic acid. When, however, it is necessary to use 
the sound without the speculum, the vagina should be thoroughly 
douched out with a 1 : 2000 solution of bichloride of mercury. The 
sound should be kept scrupulously clean, and be dipped in a 5 per 
cent, carbolic solution the last thing before its introduction. The 
spiral sound should be boiled after use in every septic case, and 
only used when the other sound does . not give the information 
sought. 

The softened uterine body has been perforated many times by 
the sound without serious results. In such cases the instrument 
passes almost its entire length, and can be felt bimanually through 



EXAMINATION OF THE FEMALE PELVIC ORGANS, 35 

the abdominal walls. The only danger consists in carrying sepsis 
into the peritoneal cavity — not a very serious one if the proper 
antiseptic precautions have been taken. 

It has occasionally happened that the sound has passed into a 
Fallopian tube. This is especially liable to occur in a uterus bicor- 
nis, and does no harm unless force is used or sepsis introduced. 
It is best never to use a sound where it is possible to gain the 



Fig. 19. 



Cs 




Sims' Uterine Elevator. 



desired information by other means. In all but exceptional cases 
this may be easily accomplished, and consequently the use of the 
sound has in great part been dispensed with. 

The Uterine Elevator. 

Another important, although at the present day infrequent, use 
of the sound is as a uterine elevator to replace the retro verted uterus. 
It has been variously modified, so that the angle can be changed 

Fig. 20. 




Elliott's uterine Elevator. 



by a screw or appliance on the external end. Such modifications 
ai:e, however, objectionable, in that it is impossible to determine 



Fig. 21. 







Emmet's Uterine Elevator. 



just how much force is being used, and whether or not the endo- 
metrium and uterine walls are being injured. By giving the uter- 



36 



AN AMERICAN TEXT- BO OK OF GYNECOLOGY. 



ine sound a proper curve and sweeping the outer end around a 
circle, the fundus can be elevated and the amount of resistance used 
easily gauged, and the use of much force avoided. 

Fig. 22. 




,/ 



Replacement of the Uterus with the Sound. Upward curve of the handle without altering the position 

of the uterus. First motion. 

Fig. 23. 




Replacement of the Uterus with the Sound. Depression of the handle so as to tip the fundus upward and 

forward. Second motion. 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 37 
Byford's elevator, made by cutting oflf the sound at its point of 



Fig. 24. 




Byford's Uterine Elevator. 

emergence from the uterus and placing a finger-cap upon it at right 
angles, gives the requisite accuracy and delicacy of touch. It is 
introduced and the cap pushed in the direction opposite to that the 
fundus is to take. When the fundus rises high in the pelvis the 
finger readily slips into the cap and is held there by atmospheric 
pressure. The long axis of the sound and long axis of the finger 
are at right angles to each other, and thus the position of the fundus 
always known. 

The Speculum Examination. 
The methods already described will usually suffice for ordinary 

Fig. 25. 




Action of Byford's Uterine Elevator. 



38 



AN AMERICAN TEXT- BO OK OF GYNECOLOGY. 



diagnosis, but when an ocular inspection, local treatment, or plastic 
operation becomes necessary, a speculum must be used. 

The simplest and most nearly allied to a perfect exposure of the 
parts is obtained by the use of a perineal retractor, in the lateral or 



Fig. 26. 




Sims' Retractor. 



Sims' position. When the patient is sufficiently turned on the breast 
and the perineum drawn back, the uterus and anterior vaginal wall 



Fig. 27. 




Sims' Speculum. 



sink away from the outlet and leave all the interior of the vagina 
exposed to view except the part covered by the instrument. If the 
patient be tightly laced or not sufficiently turned on the chest, the 



Fig. 28. 




Sims' Double End Depressor. 

anterior vaginal wall will not be drawn far enough up behind the 
pubes. We may then have to use a depressor to push it out of the 
way. If we wish to get a closer view of the cervix, we can draw 
it nearer to the pubes by means of a tenaculum. This is also 
useful in steadying the cervix for the introduction of the sound. 
The uterine dressing forceps, of which a great variety have been 
devised, are invaluable in enabling us to wipe out the cervical mucus 
and disinfecting the vaginal fornices before using the sound. When 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 39 

Fig. 29. 




Sims' Speculum Introduced. 

the mucus is too thick and tenacious to be wiped off, we can coagu- 
late it by repeated applications of astringents or soften it with strong 



Fig. 30. 



Tenaculum. 



alkaline solutions. For making uterine applications, uterine appli- 
cators and intra-uterine syringes have been devised. The applica- 



FiG. 31. 




Byford's Uterine Dressing Forceps. 



tors usually consist of a flattened piece of flexible metal, preferably 
silver, or a silver probe flattened on the end and without any bulb- 



40 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



ous or other enlargement. A small flat piece of common cotton is 
wound tightly around it, dipped into the solution, and passed into 



Fig. 32. 




Bozemau's Uterine Dressing Forcei)s. 



the uterine cavity as far as desirable. Common cotton is preferable, 
as the medicines to be applied do not soak through it quickly, so as 



Fig. 33. 



Emmet's Uterine (Silver) Applicator. 

to corrode the instrument before it can be removed. The syringe 
is made of hard rubber, and is used by being introduced to the 

Fig. 34. 




Goodell's Speculum. 
Fig. 35. 




Talley's Speculum. 



fundus of the uterus and the contents injected into the uterine cavity. 
Vaginal tampons are easily introduced and adjusted in the Sims' 
position, for the vagina is expanded and the uterus is well up in the 
pelvis. 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 41 

The Introduction of the Perineal Retractor requires some expla- 
nation. The double retractor, or Sims' speculum, is the one ordi- 

FiG. 36. 




Higbee's Speculum. 



narily used. After throwing a sheet over the patient the clothes 
are pushed up, the edge of the sheet tucked under the right or upper 
thigh, and the lower one, unless covered by the patient's drawers, 



Fig. 37. 




Brewer's Speculum. 



is covered by a napkin. The speculum is grasped in the right hand 
with the index finger along the concavity of the blade, and pushed 



Fig. 38. 




Taylor's Speculum. 



into the vagina with the convexity and handle toward the sacrum, 
while the labia are held apart with the fingers of the left hand. 



42 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



The end of the blade is passed well back toward the hollow of the 
sacrum, and the perineum drawn away from the urethra so as to 
open up the vagina. An assistant then grasps the shaft of the 
retractor in his right hand, the thumb resting against the under 
surface of the outer blade, and with the left hand holds the nates 
up to the edge of the speculum. The left forearm of the assistant 
should rest upon the patient's hip, while the right elbow and fore- 
arm rest against his own body. This ensures against unsteady 
traction and early tiring on the part of the assistant. 

The objection to the use of Sims' speculum in ordinary office 
practice is the necessity of having an assistant. Many ingenious 
modifications and appliances have been devised to retain the re- 
tractor, but as these require the use of a belt or shoulder-strap, their 
application is time-consuming and troublesome. 

On account of these objections the Sims' speculum has not been 
able to displace the self-retaining bladed specula that are used in 
the dorsal position. For inspection of the cervix and the ordinary 

Fig. 39. 




Nott's Trivalve Speculum. 



local treatment at the office the bivalve and trivalve instruments 
answer quite well. Through them the mucus can be wiped out, 
the fornices disinfected, the sound passed, the cervix dilated, intra- 
uterine applications made, and tampons placed. 

Two or three sizes or varieties are requisite to enable one to fit 
all cases. Among the best are Talley's, Higbee's (three sizes), 
Goodell's, Brewer's, and Taylor's bivalve specula. Nott's and 
Nelson's are good trivalve instruments. 

The cylindrical speculum, formerly so popular, is now seldom 
used in this country, as the exposure is too limited and the space 



EXAMINATION OF THE FEMALE PELVIC ORGANS, 43 

within it too cramped. Fergusson's is the one usually found in the 
stores. 

The right index finger first ascertains the position of the cervix, 

Fig. 40. 




Nelson's Trivalve Speculum. 



and is then held just within the vaginal entrance, while the thumb 
holds the right labium aside. The speculum is passed between 
the thumb and finger, with its upper blade laid diagonally on the 



Fig. 41. 




ITRUAX & Co 



Fergusson's Speculum. 



right finger, until it passes into the vagina. As the speculum 
touches the vulva, the left middle finger should push the right 
labium well outward to prevent hairs or folds of the labia being 
dragged into the vagina. If such has happened, a very slight 
separation of the blades of the speculum releases the parts. The 
instrument is then turned so that the lower longer blade lies flat 
against the perineum and is passed on under the cervix. As the 
blades are separated, the upper one comes up just in front of the 
cervix and exposes it. With proper manipulation neither the 
sound nor tenaculum is ordinarily needed to bring the cervix within 
the field. When the cervix is well back and the vagina narrow, 
a long speculum, such as Taylor's, should be used ; when the vagina 
is capacious, a large, short one, well expanded, serves better ; such 
as Talley's, a large Higbee, or Brewer's. A medium-sized Higbee 



44 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



answers for the majority of cases. In virgins a small Higbee sel- 
dom fails to give satisfaction. The bivalve speculum should not be 
tightly closed when removed, for fear of pinching the labia or catch- 
ing the hairs. For diseased conditions of the vaginal fornices a 



Fig. 42. 




Higbee's Speculum Introduced. 

Nelson or Nott speculum often answers better, although not so well 
as the Sims' in the lateral position. 

The sound can ordinarily be passed into the uterus through 
the speculum without trouble, although in cases of anteflexion 
with a small cervix and vagina, the cervix will sometimes have 
to be hooked forward with a tenaculum. The greatest difficulty 
to the beginner consists in passing the sound in a case of anteflex- 
ion with retroversion. 

Fig. 43. 




Passage of the Uterine Sound, in Case of Retroversion and Anteflexion. 

This is, however, easily done by pressing the well-curved sound 
first toward the hollow of the sacrum, until arrested at the bend 
of the uterus, and then causing the handle to describe a semicircle, 



PLATE VIII. 

FlC4. 1. 




Exposure of the Cervix through s^ims's Speculum. 
FiG. 2. 




Simon's Position showing use of Retractors. 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 45 

when the probe end will point upward ; it will then readily pass to 
the fundus. It often seems to the beginner as if the sound had 
passed through a spiral or corkscrew canal. The same manoeu- 
vres, reversed, may be employed for sounding a sharply-retroflexed 
uterus. 

In introducing tampons the cervix should be pushed in the 
direction it is to be held, and the tampons placed against or around 
it and held there by the forceps, until the speculum is partly with- 
drawn. When more tampons are needed they may be introduced 
and held until the speculum is withdrawn over them also. In ordi- 
nary treatment it is best not to use too many large tampons, since 
they over-distend the vagina and weaken its walls. 

Examination in the dorsal position with vaginal retractors 
(Simon's method) is one of the most satisfactory methods, but 
usually requires the use of an anesthetic to display its advantages. 

A broad perineal retractor holds back the perineum, and nar- 
row ones keep the bladder or lateral vaginal walls out of the way. 
The cervix can usually be drawn down to the vulva by tenaculum 
forceps. Simon's retractors are seldom used in this country on 
account of their cumbersomeness. Lighter modifications are more 
often employed. 

Fra 44. 




Simon's Retractors ; Removable Aseptic Handles and Joints. 



The speculum and perineal retractor are not, strictly speaking, 
instruments of diagnosis, for they reveal nothing that the finger 
cannot diagnose, except the color of the cervix and the character 



46 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



of the secretions issuing from its canal. Sims' speculum is best 
adapted for local treatment and for minor operations ; the bladed 
speculum for local treatment ; the Simon retractors for minor and 
major operations. 

Fig. 45. 




Jackson's Perineal Retractor. 



Dilatation of the Genital Tract for Examination, — It often hap- 
pens that a satisfactory examination is impossible on account of the 



Fig. 46. 



L 







H.<IU.f^ 4.| 



Byford's Lateral Vagina] Retractor. 



narrowness of some portion of the genital tract. In virgins the 
hymen may not admit the fingers without great pain, and it may 
be necessary to make the first examination under anesthesia. In 
some cases we can succeed without an anesthetic by dilating the 
parts slightly and progressively at the first few sittings. We can 
sometimes introduce only the little finger (well lubricated) the first 
time. In two or three days the index finger may gain entrance, and 
the next time the smallest Higbee speculum. When we succeed 
in getting in the speculum, it should be allowed to remain a few mo- 
ments, then slightly expanded, and a small glycerin tampon pushed 
through it into the vagina and left for twenty-four hours. The next 
time a larger tampon should be left. After this the cervix may be 
exposed, and all difiiculty will soon disappear. Similar manoeuvres 
may be made with the smallest-sized Sims' speculum. A vir- 
gin should, however, but rarely be examined. Should it become 
necessary, a rectal examination will usually answer all purposes ; 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 47 

but if this is found not to be satisfactory, the patient should be 
first anesthetized. 

Very often a conical, flexed, or imperfectly developed cervix will 
prevent examination and treatment of the uterine cavity. In such 
cases the cervix should be drawn forward by a strong hook or vul- 
sellum forceps, and some form of a tent or a dilator of small size 
gently forced into its canal. In some cases nothing can be made 
to enter without causing too much pain, except a slippery-elm tent 
but little larger than a crocheting needle, whittled out of a fresh 
piece of slippery-elm bark, moistened in a 5 per cent, aqueous car- 

FiG. 47. 




Elm Tent, whittled from fresh slippery-elm bark. 



bolic-acid solution, and slightly crushed in the jaws oi the dressing 
forceps to render it flexible. After two or three such treatments 
larger ones can be passed, and finally a small Hank's dilator or a 
delicate block-tin sound bent at a proper angle. We will then be 



Fig. 48. 




Elm Tent, after being moistened and bent, ready for introduction. 

able to explore the cavity with a small dull curette for softened 
mucous membrane, debris of malignant growths, etc. Schultze has 
recommended the introduction of a piece of sterilized lint or gauze 
into the vagina, and its removal in a few hours for the purpose of 
examining the secretions adherent to it. 

When a more extensive dilatation is required, the vagina and 
uterus may be thoroughly swabbed out with a 5 per cent, solution 



48 



^iV^ AMERICAN TEXT-BOOK OF GYNECOLOGY, 



of carbolic acid or a 1 : 2000 solution of bichloride of mercury, and 
a long narrow strip of iodoform gauze pushed into the uterus until 
it fills the entire cavity and projects from the cervix, partly filling 
the vagina. This may be left for twenty-four hours, and replaced 



Fig. 49. 




Hank's Uterine' Dilator. 



by a larger packing each day until the uterus becomes sufficiently 
dilated to admit the finger for palpation. These packings should 
be introduced at the patient's house or at a hospital, and the parts 
thoroughly disinfected before each packing. The packing should be 
examined each time for any abnormal secretion that may be found 
upon the uterine end. Unless the most perfect antiseptic precau- 
tions are assured, the packings should not be repeated many times, 
for the mucous membrane becomes denuded of its epithelium and 
exceedingly susceptible to septic inflammation. Vulliet was the first 
to systematically employ intra-uterine packing of this kind for the 
purpose of dilating and exploring the uterus. 

Rapid Dilatation of the Uterus for diagnostic purposes is usually 
made under anesthesia, for which either the Sims' or Simon method 
of exposing the cervix may be employed. The cervix is drawn for- 
ward and steadied by a strong hook or vulsellum forceps. Conical 

Fig. 50. 




Nott's Dilator, 



dilators of constantly increasing sizes may then be forced into the 
uterus until a large curette or a finger can be used to explore the 
cavity. It usually requires an hour or so to dilate wide enough 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 49 

for the introduction of the index finger. In this country the 
bladed dilators are usually preferred. It is preferable to use two 
or three sizes of these, first introducing a Nott's or Ellinger's, closed, 
and expanding the blades until the canal is large enough to admit 

Fig. 51. 




Goodell's Dilator. 



a larger instrument, such as Goodell's, which in turn is expanded. 
The dilators should be turned from time to time so as to stretch 
the cervix antero-posteriorly, as well as laterally, and thus secure 
a greater and more general relaxation The blades of EUinger's 
and Goodell's instruments remain parallel during expansion. 
It is sometimes almost impossible to dilate the nullij)arous cervix 

Fig. 52. 






Sponge Tents. 



at a single sitting wide enough to admit the finger to the fundus with- 
out lacerating the cervix. Hence in some cases only a , moderate 
dilatation is attempted, and this is followed up by Vulliet's method 



50 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



of tamponmeiit. After abortions, or when the uterus is enlarged by 
growths or relaxed by inflammatory action, wide dilatation is often 
quite easily and rapidly accomplished. 

In other cases in which it is considered necessary to introduce 
the finger, the cervix is split on either side as high as the vaginal 
junction with scissors, and the incision deepened within by a probe- 
pointed bistoury or hysterotome. The incisions are sewed up 
immediately after the examination. This obviates the bruising of 
the cervix, yet the internal os and lower uterine segment may be 
so small that even this method fails to help us much. It is indeed 
seldom made use of for diagnostic purposes. 

Gradual Dilatation by means of sponge tents, tupelo tents, 1am- 
inaria tents, cornstalk tents, etc. was a once popular method that 

Fig. 53. 







Tupelo Tents. 

has now fallen into disuse, except in isolated cases in which the 
other means cannot be conveniently employed. 

Sponge tents expand quite rapidly, but they abrade the mucous 



EXAMINATION OF THE FEMALE PELVIC ORGANS, 51 

membrane and sink into the cervical folds, so that portions of 
them are apt to be left after removal. This, together with the 
fact that two or three must be successively used to obtain suffi- 
cient dilatation, exposes tlie patient to great danger from sepsis. 
The mortality attending their use is great; the danger increases 
with each tent used. A 1 : 2000 bichloride vaginal douche should 
always precede their introduction and follow their withdrawal. 
They are best introduced in the lateral position by the aid of a 
Sims' speculum, and should each be left in situ four or five hours. 
Tupelo tents are firmer and expand more slowly and efficiently. 
They slip out easily, and must be kept in place by a vaginal tampon. 
The same accidents are liable to happen as in using sponge tents, 
and the same precautions must be taken. 

Fig. 54. 





Laminaria Tents. 



Sea-tangle or laminaria tents often expand unequally, with a con- 
stricted zone corresponding to the internal os, which renders their 
removal difficult. 

Fig. 55. 




Laminaria Tents dilated in the Uterus, showing constriction by the internal os. 



DilaMtion of the Urethra for digital examination and exploration 
of the bladder was recommended by Simon, and has been made use 
of frequently. The danger of incontinence of urine has, however, 
deterred many from attempting it, and unless an hour or more is 



52 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



taken for the procedure this accident is very liable to follow. 
Urethral sounds or dilators of graded sizes should be slowly and 
successively introduced until the little finger can enter the bladder. 



Fig. 56. 



BGr. 



liBlV 




TrL' 



Palpation of the Interior of the Bladder. BGr, a a a, base of bladder: b b, mouths of ureters; TrL, 
interureteric ligament; hBW, posterior wall of bladder. 

The anterior uterine wall, ureteral mouths, and inner surface of 
the bladder can be explored. In many cases the ureters can be 
catheterized. In conjunction with one hand over the abdomen an 

Fig. 57. 



Wire Curette. 



accurate bimanual examination of the anterior half of the jDelvic 
cavity can be made. 

The Dull Curette is a useful instrument in scraping out retained 



Fig. 58 




Exploratory Curette. 



secundines after abortion, or portions of intra-uterine malignant or 
adenomatous growths for macroscopical and microscopical examina- 
tion. The sharp curette is, however, a much safer and efficient 



EXAMINATION OF THE FEMALE PELVIC ORGANS. 53 

instrument for this purpose. They can be used after moderate 
dilatation with conical or bladed dilators. The small exploratory 
curette may be used for the same purpose, with the added advan- 
tage during its use of not being forced to dilate the cervical canal. 
The Exploratory Needle or Syringe is a valuable aid in the 

Fig. 59. 




Exploratory Needle and Syringe. 

diagnosis of pelvic abscesses or cystic tumors, when such aid is 
needed, which is of rare occurrence. It consists of a hollow needle 
or small trocar that can be attached to a syringe. After an anti- 
septic vaginal douche the patient is put upon the back, and the 
sterilized needle pushed into the tumor at a point in the disin- 
fected vagina where no pulsating vessel can be felt. If the needle 
be a fine one, there will be little danger even if the bladder, rectum, 
or a small blood-vessel be punctured, except from infection of 
the cyst contents, if it be not already septic. A few drops of fluid 
are drawn for inspection. 

An Aspirator m'dj be used in the same way as the exploratory 
needle, the chief difference being that more fluid, or even all of it, 
can be withdrawn. 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 



Technique, in gynecology, is a word used to designate certain 
features in the details of an operation essential to its proper per- 
formance, and is the most powerful factor in ensuring its success. 
It has nothing to do with the diagnosis, the prognosis, or the 
determination to operate, but, having determined to operate, it 
concerns itself with every act, from the preliminary preparations 
to the completion of the operation. To assert, therefore, that the 
technique in a given operation is faultless, is to credit the surgeon 
with the highest scientific knowledge of his specialty, and the 
skill to properly utilize it for the benefit of his patient. 

Imperfect technique implies errors of omission or commission 
on the part of the operator which may prove detrimental to the 
recovery of the patient, even costing her life. With a perfect 
technique, therefore, the surgeon is acquitted of personal respon- 
sibility as to the result, providing his judgment in electing to 
operate has been good ; while if his technique is bad he always 
stands arraigned before the bar of criticism, and is from time to 
time directly responsible for the bad results, of his work. 

The technique of an operation is thus made to include all those 
features which scientific investigation and consensus of opinion have 
shown to be conducive to success in the greatest number of cases. 

It has nothing to do with dexterity, rapidity, or any other 
personal element in the operation, but is the basis or pervading 
principle of the work. 

As it is the animating principle of successful operations, it 
is in the highest degree important to devote a separate chapter 
in a practical work on gynecology to the consideration of such 
technical details as are more or less common to operations in gen- 
eral, or to certain classes of operations. The variations in the 
technique of each individual operation must be left to the syste- 
matic description of the operation in its appropriate chapter. 

54 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 55 

The evolution of gynecology to its present high position as a 
specialty is due to improvement in the technique of its operations. 

In the earliest times there was no technique : the operator treated 
each case according to his own inclinations. Gradually, as the re- 
sults of observations accumulated, individual operations crystallized 
in definite forms, and the technique of the operation was thus estab- 
lished. Further experience demonstrated the existence of certain 
underlying principles common to groups of operations, and culmin- 
ated in one grand principle, antiseptic technique. This principle 
has proved the quickening element in the whole field of modern 
gynecology, giving life to old operations, calling new operations into 
existence, and yearly saving thousands of lives. 

Sepsis, Asepsis, Antisepsis. 

A proper realization of the significance of these three terms to 
practical gynecology constitutes the very essence of successful scien- 
tific work. The cause of death after operation in the vast majority 
of cases is sepsis or germ-infection. A large percentage of all gyne- 
cological cases under treatment are infected or septic. 

There is no longer any discussion among intelligent men as to 
whether certain forms of germs are dangerous and destructive to life, 
but the question is : under what circumstances do these germs in- 
vade the tissues, and what are the best methods for excluding them? 

Sepsis is the condition of infection resulting from the presence 
of one or more specific organisms, such as the Staphylococcus 
pyogenes aureus. Staphylococcus pyogenes albus, Streptococcus 
pyogenes. Bacillus colis commune, Gonococcus Neisseri. 

Any of these organisms may be found pre-existing in the genital 
tract ; the first and third are found in tubal abscess. The second 
affects chiefly stitch -hole abscesses. The colon bacillus exists in 
the intestinal tract, and may occasion a general peritonitis after an 
operation, if the intestine is 'seriously wounded. Streptococci are 
for the most part found in the purulent inflammatory conditions 
following abortion or puerperal fever. 

These are often peculiarly virulent, and a little of the pus re- 
maining in the pelvis is often suflicient to cause the death of the 
patient by a rapidly-developing peritonitis. 

The most harmless pus is that containing gonococci. It is prob- 
able that these organisms die early, and for this reason the pus is 
more or less innocuous. Septic infection is introduced into wounds 



58 AJV AMEBICAN TEXT-BOOK OF GYNECOLOGY. 

by the fingers of the operator, instruments, sponges, ligatures, or 
other objects not properly sterilized. 

Asepsis means freedom from septic germs, and is the ideal condi- 
tion for the hands of operator and assistants and the surgeon's 
armamentarium. 

The surfaces of all objects exposed to the air are coated with 
germs ; the hands not only become contaminated, but the bacteria 
multiply beneath the finger-nails, and the most virulent germs may 
thus be easily transported from case to case. Relative to the opera- 
tion, therefore, all objects not specially prepared and cleansed are 
germ-infected or septic. 

Antisepsis is the application of any efficient means for getting rid 
of germs. It may be mechanical^ as by scrubbing or washing ; 
chemical, as by the use of carbolic acid or bichloride of mercury ; 
or thermic, by boiling water or steam. 

Mechanical antiseptic measures are of the utmost value in remov- 
ing those germs from the hands which can be easily dislodged; 
by this means, however, the hands cannot be rendered sterile or 
germ-free. This is to be attained by immersing them successively 
in saturated solutions of permanganate of potash and oxalic acid. 
The hands should not be introduced into the abdomen without first 
washing off the oxalic acid in sterile water. 

Chemical sterilization by drugs is becoming less and less import- 
ant. A prolonged immersion of the hands in bichloride-of-mercury 
solutions as strong as 1 : 500 does not render them so sterile as the 
permanganate of potash and oxalic acid, yet practically it answers 
the purpose and is used by a large number of operators. Carbolic 
acid cannot be used for this purpose in efficient strength without 
injury. Sterilization by steam and boiling water have with complete 
satisfaction replaced all other measures. 

An exposure to steam heat at 100° C. or 212° F. for a half hour 
will destroy all germs in cotton, gauze, bandages, or other dressings. 
If repeated on two successive days the spores are destroyed, and 
objects so treated will remain sterile until exposed to contamination. 
A boiling 1 per cent, solution of the carbonate of soda will sterilize 
instruments in five minutes without tarnishing them. 

Technique in General. 

1, Operating-room; 2, Surgeon, assistants, nurses; 3, Instru- 
ments ; 4, Ligature and suture materials ; 5, Dressings. 



THE TECHNIQUE OF GYNECOLOGICAL OPEBATIONS. 57 

1. Operating -room. — The requisites for a gynecological operating- 
room are a floor on which water can be freely used, a good illumina- 
tion, and an abundant supply of hot and cold water. A closely 
joined wooden floor, if well parafiined, is, with a little care, per- 
fectly satisfactory. The best floor, however, is made of encaustic 
tile, closely-laid, as it will not absorb moisture. 

The light of the operating-i-oom should come from windows on 
the north and from a large skylight. Too strong light or direct 
rays from the sun embarrass the operator and spectators by blind- 
ing the eyes and throwing the parts below the surface into deep 
shadows. 

Fig. go. 




Sterilizer, Demijohn, Basin-holder, Sponges, Drainage-tubes, Syringes, Sutures, etc. 

Hot and cold water should be on tap in abundance. Hot water 
circulating in pipes is usually sterile. Cold water will do for the 
purpose of preliminary cleansing and for washing the hands, but 
should in no w^ay come in contact with the field of operation unless 
previously sterilized by boiling. 

If the operating-room is sufliciently large, it may contain sev- 
eral wash-basins, each supplied with hot and cold water, a wash- 



58 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



Fig. 61. 




Instrument Table with Glass Trays. 



sink with a large water-supply and drip-stones near by for dishes,^ 
and the apparatus for steam disinfection, also vessels for boiling 



soda solution, and for boiling water. 



Fig. 62. 




Sink, Sterilized Water, Arnold's Sterilizer, etc. 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS, 59 

In another part of the room ligatures, gauze drains, sponges, and 
sterilized gauze and cotton are stored on shelves along with the 
glassware. 

The instrument-case should be provided with glass shelves, as 
they are easily kept clean and expose all the instruments to 
view. The instruments should be properly classified in groups — 
scissors, knives, forceps, etc. ; the artery forceps are most conve- 
niently kept in a small space by bunching six or eight on a key- 



ring. 



Fig. 63. 




Instrument -Case and Sterilized Water in Bottles. 



Adjoining the operating-room is a small room for the adminis- 
tration of anesthesia. The patient is brought here from the ward 
and anesthetized without witnessing any of the preparations wiiich 
have been made for her reception in the operating-room. 

After each operation the floor is .cleansed by mopping with water. 
Occasionally the walls should be gone over with a damp cloth. 
A good enamel paint will resist the discoloring effects of the 
moist atmosphere of the room. 

Some operating-rooms are conveniently arranged with subsid- 
iary rooms in which all the preparations for an operation are made, 
leaving the room for the operation perfectly clear for operator, 
assistants, and spectators. This is the more convenient arrange- 
ment where the operations are frequently performed in the pres- 



60 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



ence of large classes. These same principles may be carried out 
in a private residence as efficiently, if not so elaborately, as in the 
hospital. 

The accompanying cut of one of the operating-rooms of the 
Gynecean Hospital, Philadelphia, prepared for an operation, shows 



Fig. C4. 




Etberizing Room. Patient being etherized. 

at a glance how easily and simply the indications can be met. It 
will be seen that there are but few articles in the room which can- 
not be obtained or substituted in any well-regulated private resi- 
dence. A plain kitchen table may be made to answer the purpose 
of the operating-table. If it is desirable to use the Trendelenberg 
position, a Krug frame can readily be taken to the house in the 
physician's carriage. Instruments may be boiled in any conve- 
niently-sized tin basin. Five- or ten-gallon demijohns of dis- 
tilled water are readily obtained, but if not, boiled water will 
answer all purposes just as well. If it be muddy, it should of 
course be filtered. 






c 



Q 



& 





I— I 




THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS, 61 

The Operatok and his Direct Assistants. 

The responsibility of the operator and his assistants does not 
begin, as it is commonly believed, in the preparation immedi- 
ately before the operation. It is a duty constantly devolving 
upon all persons who come in direct contact with wounds of any 
sort, to avoid in every possible way and at all times unneces- 
sary contact with septic matter. Unhealthy or suppurating wounds 
should never be touched with the fingers when it is possible to 
avoid it ; dressings of such wounds should be removed and replaced 
by forceps. 

The gynecologist has no right to conduct post-mortem exami- 
nations or handle pathological specimens. When contact with 
possibly infected objects is necessary, the lodgment of infection in 
the skin and under the nails should be prevented as far as possible 
by coating the surface of the fingers and hand with vaseline, and 
making the contact as brief as possible ; and this should be fol- 
lowed immediately by a thorough scrubbing in clean warm water. 

The surgeon and his assistants, like obstetricians, should avoid 
the habit of wearing gloves which cannot be washed. Contam- 
ination is sometimes, undoubtedly, conveyed by examining a septic 
case, hurriedly washing the hands, and drawing on gloves which 
become thus contaminated, and which in turn reinfect the hands 
each time they are worn. 

Both surgeons and assistants should bathe frequently and wear 
clean apparel. It adds to the comfort, as well as harmonizes with 
the sense of cleanliness, if the surgeon can step from his bath into 
his operating suit. Operating suits for surgeon and assistants should 
be made of stout butcher's linen. The jacket should be open in 
the back ; the pantaloons may be separate or attached to the jacket. 
Tapes should be used in place of buckles for the pantaloons. The 
sleeves should be short, reaching to within two or three inches of 
the elbow. Before putting on the suit the outer clothing should be 
removed down to the under-clothes. It is in better keeping with 
the appearance of the rest of the costume to wear white canvas 
shoes with rubber soles. The nurses must wear wash dresses with 
fresh white front and short sleeves. 

For operations in private houses aprons of stout butcher's linen 
sufficiently long to cover the clothing from the neck to the ankles 
will give the proper amount of protection. 



62 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



Cleansing the Hands and Forearms, 

The first duty after entering the operating-room is to cleanse the 
hands and forearms thoroughly at the basins with a sti if scrubbing- 
brush, common brown kitchen soap, and warm water ; frequently 
changing the water. The best brushes for this purpose are made 
of vegetable fibre and cost but twelve or fifteen cents apiece. At 
least ten minutes must be spent in scrubbing the hands and fore- 
arms, paying especial attention to the finger-nails. 

Fig. 65. 




Sterilization of Hands with Permanganate of Potash : Costume of Operator and Assistants. 

After washing the hands and forearms they are covered with a 
hot saturated solution of permanganate of potash until they are 
stained a deep mahogany-red, when they are immersed in a hot 
saturated solution of oxalic acid and moved about until all the 
stain of the permanganate is removed. The hands may then be 
immersed in milk of lime or in plain water to wash off the oxalic 
acid. The nurses who handle sponges, gauze, prepare ligatures, 
etc. must also wash and sterilize their hands in the same way. 

A common and excellent substitute for this method of steriliza- 
tion is to bathe the hands and arms in alcohol after scrubbing them 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 63 

with the nail-brush and soap. They are then soaked in a strong 
bichloride-of-mercury solution (1 : 500) for five minutes, and the 
bichloride is finally washed off with distilled water. 

After such a preliminary sterilization the operator must avoid, 
as far as possible, contact with non-sterilized objects, such as lids 
of jars and vessels, door-handles, tables, or the patient ; above all 
must such inconsistencies be avoided as shaking hands with visitors, 
putting the hands in the pockets while waiting, etc. 

When necessary to come in contact with the patient, as in 
placing her on the pad, in rearranging her clothes, or in removing 

FiC4. ^Q. 




Washing away Permanganate of Potash with Oxalic Acid Solution. 

bandages, the hands must again be sterilized by washing for two 
minutes, omitting the permanganate of potash and oxalic acid 
solution. 

Instruments. 

After each operation the instruments are immersed in hot water 
and scrubbed with brown soap and a scrubbing-brush. They are 
then rinsed in hot water and placed upon a clean dry towel, and 
rapidly dried, the heat from the water assisting in this process. 



64 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



After drying the instruments tliey are classified in separate groups 
on the shelves in the instrument-case. Before the next operation 
they are collected in a linen bag and placed in the sterilizer. If 
the operation has been a septic one, they are sterilized before put- 
ting them away, and again just before the succeeding operation. 
The sterilization of instruments is simplv and efficiently effected 

It/ ty 

by boiling them in a solution of carbonate of soda, of 1 per cent, 
strength, for five minutes. The bag is then picked up by the 
draw-string, which has been left hanging out over the edge of the 

Fig. 67. 




Placing Instruments in Arn id -Ltiilizer, in Linen Bag. 

vessel, and carried to the instrument dishes, into one of which it is 
emptied. If a wire or perforated tray be used upon which they 
are boiled it may be lifted from the sterilizer, placed on the instru- 
ment-table, and the instruments used directly from it. Cold water 
is poured over the instruments, and when cooled they are appro- 
priately classified. The instruments should be kept bright and free 
from tarnish by the occasional use of a fine soap, such as sapolio, 
used for polishing metallic surfaces. 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 65. 



Ligatures and Suture Materials. 

The ligature and suture materials used in gynecology are silk, 
catgut, and silkworm-gut. 

Silver wire, much used formerly, is now more than replaced 
by silkworm-gut, which possesses all of its advantages with none 
of its disadvantages, and in addition has other points of superiority. 
Tendon sutures, while excellent, are too expensive to come into gen- 
eral use. The silk should be of the twisted Chinese variety of 
three grades — fine silk, used as carrier threaded in a loop, by means 
of which the sutures are pulled through the tissues ; intermediate 

Fig. 68. 




Silk in Tubes for Sterilization. 



silk, for all ordinary purposes of suture and ligature, even for ligat- 
ing the ovarian and uterine arteries and approximating the edges 
of the stump in hysterectomy for myoma; and heavy silk, for 
ligation in vaginal hysterectomy. 

The silk is sterilized by placing it in stout glass tubes made 
for this purpose, or in pieces of stout glass tubing an inch in 
diameter, plugged at both ends with cotton. The silk should be 
cut in convenient lengths and rolled loosely on glass reels which 
fit the inside of the tube. The tube is then placed in the ster- 
ilizer, steamed for an hour, taken out, and the process repeated 
a half hour on two succeeding days. The cotton is left in place 
until the sutures are ready for use. The ligatures are sterilized by 

5 



66 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

this fractional sterilization with absolute certainty, as this is the 
method employed in the bacteriological laboratory for sterilizing 
culture media. It must not be forgotten that the steam penetrates 
the cotton and circulates with perfect freedom in the tube. 

Of the sterilizers thus used, that of Arnold is the best for trans- 
portation and for clinics not fitted with special conveniences. 

Where steam is constantly circulating through the establishment, 
it may be conveniently utilized for sterilization by tapping the pipe 
into a copper cylinder. A coil of pipe filling the inside of the cylin- 
der, also connected with the steam system, serves to keep up a high 
temperature, and to dry out the dressings when the free steam is 
turned off. 

Silkworm-gut is sterilized in the same manner as the silk. It 
should be assorted into light and heavy sizes. 

Catgtd. — Catgut is ruined by water or steam, and requires there- 
fore a different mode of sterilization. The method commonly 
adopted is by prolonged boiling in alcohol from one to several 
hours. The best apparatus so far devised for this purpose is David's, 
in which the vapor of the alcohol is recondensed and the loss of 
alcohol largely prevented. Very heavy catgut is dangerous, and 
should never be used, no matter how prepared. Fine and inter- 
mediate catgut may be used for buried ligatures or sutures, after 
sterilization in alcohol for an hour the first day and a half hour 
on two successive days. It is most convenient to roll it on glass 
spools and preserve in glass-stoppered jars filled with alcohol. At 
the time of operation the jar is opened and the catgut with the 
alcohol turned out into a small glass dish. It must not come in 
contact with water. 

The method of sterilization by boiling in alcohol is still on trial. 
Theoretically, it would seem to be unreliable. Alcohol boils at 
173° F., which is not sufficiently high to kill the spores of 
some germs with which the material is liable to be infected. A 
common substitute for this method of sterilization of catgut is to 
immerse it in ether for from two to seven days, changing the ether 
several times during this interval. From the ether it is transferred 
into an alcoholic solution of bichloride of mercury, 1 : 100, in which 
it is allowed to remain for forty-eight hours. It is finally trans- 
ferred into a solution of 1 part of the oil of juniper wood to 2 parts 
of alcohol, where it is kept, securely corked, until needed, when it 
is immersed in commercial alcohol an hour before using. Gut pre- 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 67 

pared in this manner is free from septic matter, although it is liable 
to be weakened by the preparation. 

Dressing, Sponges, etc. 

Gynecological dressings consist of absorbent cotton, simple, ster- 
ilized, and iodoformized gauze, and abdominal and T-bandages. 

Sponges are prepared by pounding them in a wooden bowl to 
loosen the grit, and then washing them in warm water until the 
water remains clear. It may be necessary to change the water eight 
or ten times. From the water they are transferred to dilute muriatic 
acid (3ii to Oj) and allowed to stand for twenty-four hours. This part 
of the process is necessary to remove all chalky particles. From 
the hydrochloric acid they are passed quickly through permanga- 
nate of potash solution (5 per cent.), which stains them a dark pur- 
ple, which in turn is decolorized by immersing the sponges in oxalic 
acid (saturated solution). Before transferring the sponges to the 
oxalic acid solution the hands should be disinfected after the same 
method as for operation, as the permanganate of potash and oxalic 
acid are the essential factors in the process of sterilization, and the 
sponges must not be contaminated from this stage on. From the 
oxalic acid solution, where they have remained only a sufficient 
time to effect decolorization, they are transferred to sterilized lime 
water, which neutralizes the acid, and then into bichloride-of- 
mercury solution (1 : 1000) for twelve hours, after which they are 
rinsed twice jn sterilized water and preserved in carbolic acid solu- 
tion (3 per cent.), until they are desired for use. 

After being washed free from the hydrochloric acid another good 
method for cleansing is to immerse the spoijges in a saturated solu- 
tion of washing soda for forty-eight hours, from which they are 
taken, thoroughly washed free from the soda, and placed in alcohol, 
in which they are kept until used. After being soiled at one ope- 
ration they may be prepared for further use by passing them through 
the saturated soda solution and allowing them to soak for twelve 
hours in a solution of sulphurous acid, sufficiently strong to be sour 
to the taste. Thev are then transferred to the alcohol. 

Absorbent cotton is unrolled from the bales in which it is bought 
and cut into pieces of various sizes or made into loose balls. The 
large pieces are laid in a towel which is pinned together, so as to 
completely protect the cotton. The balls are sterilized for an hour 
in a glass jar, which is left open during the process; at the end 



68 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



of this time the free steam is cut off and that circulating through 
the coil allowed to dry them out thoroughly. 

Gauze. — Gauze is bought in rolls of one hundred yards each, 
at a little over three cents a yard. It is cut into strips of several 
yards' length, and then sterilized in the same manner as the cotton 
and other dressings. Both gauze and cotton are used preferably by 
many operators after they have been impregnated with bichloride of 
mercury. Such material should never be used inside the peritoneal 
cavity. It may be bought already prepared in the shops. 

lodoformized gauze is prepared by impregnating rolls of sterilized 
gauze with an emulsion of iodoform in soapsuds and water. 

Fig. 69. 




Mikulicz Drain. 



The Gauze-hag or Mikulicz Drain. — This is one of the most 
efficient forms of abdominal drainage, and possesses the advantage 
over the glass tube in that it acts continuously and takes care of 
itself, while tubes require constant attention and are liable to con- 
vey sepsis down into the pelvis, as well as to perforate the bowel 
by the pressure made by the end of the tube. The gauze bag should 
be one or two inches in diameter and about eight inches long, with 
a string tied to its bottom. This is loosely filled with three or four 
long strips of gauze, about two and a half inches wide, which pro- 
ject from the top of the bag. When desired for drainage the bag 
is laid in the back of the pelvis across the area to be drained, if it 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS, 69 

be extensive, and is then brought up over the top of the uterus and 
out through the incision, and is cut ofiP about an inch beyond the 
wound. The drainage is effected by capillary attraction which car- 
ries the discharge to the surface, where there must be an abundance 
of sterilized cotton to take it up. In one or two days the strips are 
slowly drawn out with a pair of sterilized forceps, and traction is 
made upon the string which inverts the bag, and thus effects its 
removal. The part of the incision left open by the removal of the 

Fig. 70. 




Gauze Drains. 



bag is then closed by a provisional suture placed in the track of 
the drain at the time of operation. 

Roll-gauze drain is useful where long areas of denudation extend 
along the intestines or over into the flanks. This is made by 
forming a piece of gauze a yard long into a loose roll about three- 
quarters to one inch in diameter. Pieces of the length desired can 
be cut off or as in some cases the whole roll can be used. 

Although efficient, these drains are difficult to remove and cause 
the patient much distress, as they cling so closely to the skin and 
underlying tissues. 

Glass drainage is probably used more frequently than gauze, 



70 



^iV^ AMERICAN TEXT-BOOK OF GYNECOLOGY, 



but in careless hands it is exceedingly dangerous, and should be 
avoided, except when the surgeon can be absolutely sure that its 
care is in competent hands. The drainage-tube should be about 
six inches in length and of a calibre just sufficient to admit the 



Fig. 71. 




Glass Drainage-tube. 
Fk4. 72. 



\.^w\"z.a<.s^us 




Hard-rubber Syringe, for cleansing drainage-tube. 

nozzle of the syringe used in cleansing it. The object of the tube 
is to keep the cavity to be drained perfectly dry. To accomplish 
this it is necessary, at times, directly after the operation, to cleanse 
the tube every fifteen minutes. In the course of a few hours the 
intervals of cleansing are lengthened, until it is not repeated oftener 
than three or four times a day. The tube is removed as soon as the 
discharge assumes the straw color of the normal peritoneal fluid, 
and the amount is diminished to a few drachms at each cleansing. 
The tube is kept dry, while in situ, by passing a long-nozzled 
syringe to its bottom and removing the accumulated fluids by suc- 
tion. Before and after each cleansing the mouth of the tube and 
the rubber-dam through which it projects must be carefully washed 
with a piece of cotton dipped in bichloride-of-mercury solution; the 
syringe should be disinfected both inside and out with bichloride 
solution and boiling water. The hands of the person cleans- 
ing the tube must be carefully disinfected before each dressing, 
no matter how often repeated. In no other way can the safety 
of the patient be ensured. Fresh sterilized cotton is placed over 
the mouth of the tube each time it is disturbed, and is held in 
place by a square piece of rubber-dam, through the centre of which 
the free end of the tube protrudes. 

Plastic Operations. 

Preceding a plastic operation upon the vagina the bowels should 
be thoroughly evacuated by two or three free purgations, started 
with a laxative, such as a pill composed of aloes gr. j, belladonna 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS, 71 

gr. i, and strychnia gr. 3V, taken thirty-six hours before the time 
of operation, followed, if necessary, by citrate of magnesia. A Seid- 
litz powder twenty-four hours before operation followed by a rectal 
enema the next morning is also efficient. 

Occasionally the action of the purgative is delayed and feces are 

Fig. 73. 




Kelly's Leg-holder. 



evacuated over the operator's person from time to time during the 
operation ; this can be overcome temporarily, in persistent cases, by 
passing a suture twice through the anus. 

In perineal, vaginal, and rectal operations the patient is brought 



Fig. 74. 




Robb's Modification of Kelly's Leg-holder. 



down to the edge of the table, with the thighs well flexed on the 
abdomen and held in this position by a leg-holder. The simplest 
form of leg-holder is Kelly's or Eobb's modification. In the for- 
mer, one of the loops is placed under the knee and into this the 



72 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



shoulder-strap is hooked and drawn under the arm, around the 
back of the neck, down over the opposite shoulder, and hooked 
in the loop under the opposite knee. 

The leg-holder may readily be dispensed with and an assistant's 
hands substituted. 

The perineal pad is next inflated and placed under the but- 



FiG. 75. 




Assistant Supporting Legs. 



tocks, with the apron dropping into a bucket at the foot of the table. 
In vaginal operations the preparatory cleansing is conducted as 
follows: The external genitals are thoroughly soaped, and this 
worked up into suds with warm water ; the hair is next shaved 
off the vulva, although this procedure is by no means absolutely 
necessary, provided the operator takes sufficient care to render the 
hairs thoroughly aseptic ; a longer time must therefore be spent in 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 73 

the disinfection. The vagina is thoroughly cleansed with soap and 
warm water. A 10 per cent, solution of creoline makes an excel- 
lent detergent, if applied vigorously by means of a ball of absorbs 

Fig. 76. 




Perineal Pad in Position. 



ent cotton in the grasp of a pair of forceps, so as to repeatedly stretch 
out and cleanse every little fold and rugosity. The parts around 
the field of operation are protected in the following manner : A 



Fig, 77. 




Fountain Syringe used for Irrigation in Private Practice. 



74 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



diaphragm composed of three or four thicknesses of gauze is laid 
over the vulva, inner surfaces of the thighs and buttocks, reaching 
well down below the border of the table. Through a slit in the 
centre of this the operation is performed. The legs of the patient 



Fig. 78. 




Glass-jar Irrigator. 



are covered with loose, sterilized stockings reaching above the 
knees, where they are tied with draw-strings. 

The irrigator is of great service in perineal work. By its use 
sponges are dispensed with, and the blood which is at once diluted 
fails to clot, and does not cling to the fingers. 



Fig. 79. 




Baldy s Irrigating Tube. 

The best form of irrigator is a large glass jar placed on a shelf 
three feet above the head of the operator. 

An opening near the bottom provides for the escape of the water, 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 75 

which is conducted through a rubber tube ending in a glass nozzle, 
with an intervening stopcock. 

The Technique of Abdominal Operations. 

The technique of abdominal operations begins with the preparatory 
treatment of the patient immediately before operation, and includes all 
the details in the preparations for, and the conduction of, the operation. 
Certain features are common to all abdominal operations. Of these, 
but two will be described : the opening and closing of the abdomen. 

Preparatory Treatment. — It is necessary to begin in some cases 
weeks beforehand, if the patient be in an enfeebled condition and 
there is a good prospect of building her up for the operation. The 

Fig. 80. 




Operating Table with Ovariotomy Pad in Position. 

most important elements of the treatment are rest in bed, digest- 
ible diet at frequent intervals, stimulants if well borne, regulation of 
the bowels, quickening the activity of the skin by baths, massage, 
and electricity. In other cases, where the general condition is good, 
a delay of but one or two days is necessary in which to bathe the 
patient and thoroughly evacuate the bowels. Almost all chronic 
cases, not excluding pelvic abscess, will be benefited by preparatory 
treatment. 

Such cases as extra-uterine pregnancy with internal hemorrhage, 
rupture or strangulation of a cyst, or rupture of an abscess, call for 



76 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



immediate operation. Here all the advantages of rest and prepa- 
ration are subordinate to the paramount danger which is momenta- 
rily threatening to destroy life. Frequently it will be necessary to 
give the patient an anesthetic, and without preliminary preparation 
lift her on to the ovariotomy pad upon the table, where the vagina 
is douched out with a strong boric-acid solution, or a 10 per cent, 
creoline solution, or a 1 : 1000 solution of bichloride of mercury. 
The mons veneris is then shaved well down to the labia, the 
abdominal walls scrubbed, and coeliotomy performed at once. 
Opening the Abdomen, — This is the one step common to all 

Fig. 81. 




Opening the Peritoneum. 

abdominal operations, and may therefore be described as a part of 
the technique in general. 

The usual location for the incision is in the median line between 
the umbilicus and pubes, nearer the pubes. 

The abdomen is to be thoroughly washed in the ward, by first 
scrubbing with soap and hot water with the aid of a nail-brush, 
followed by alcohol and ether, and this by a strong bichloride-of- 
mercury solution (1 : 1000). The abdomen is covered with a pad 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 77 

of sterilized gauze, to prevent contamination of the skin from the 
patient's night-gown, etc. in transporting her to the operating-room. 

The patient is placed on the table with her hips resting on 
Kelly's ovariotomy pad, the apron of which hangs over the side 
of the table into a bucket. The feet rest on a support at the end 
of the table. 

The vagina is now douched, or in event of a hysteromyomec- 
tomy (hysterectomy for " fibroids ") washed thoroughly with soap 

FiCx. 82. 




Short Incision in Abdominal Wall. 



and water, followed by bichloride-of-mercury solution (1 : 1000), 
and finally packed with iodoform gauze. The assistant now 
cleanses the abdomen by first scrubbing it with a ball of cotton 
and soap and warm water, then with pure alcohol, followed by 
ether, and finally with sterilized water. 

Sterilized towels are used to protect the thighs and chest, and 
over the whole abdomen, chest and thighs a large piece of gauze, 
three folds thick, is laid. This is slit open for a short distance 
in the median line, and through the opening the operation is con- 
ducted with a minimum danger of auto-infection from the patient's 
skin. 

For making the incision a sharp scalpel, two pairs of rat-tooth for- 
ceps, and one or two short sharp-nosed artery forceps are necessary. 



78 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



The operator steadies the abdominal wall and holds the skin a 
little taut, between the thumb and middle finger of the left hand, 
while the right hand makes a sweeping incision vertically down- 
ward in the median line from two to eight inches long, according 
to the nature of the operation. In doubtful cases a shorter incis- 
ion should be made first, and afterward lengthened if necessary. 

After passing through skin and fat the sheath of one of the recti 
muscles appears. This white and fibrous layer may be cut a little 
obliquely, when the incision is almost sure to cross the linea alba, 
seen between the two red muscles. The incision is continued down 
between the muscles in the linea with the aid of an assistant, who 
catches the tissue of one side with his forceps, while the operator 

Fig. 83. 




Method of Enlarging the Abdominal Incision. 

does likewise on the opposite side. Thus the tissues are lifted up and 
drawn apart, layer by layer. The superficial fat, which is of variable 
thickness, appears next, and beneath this the thin, delicate perito- 
neum. The peritoneum must be caught very superficially in the for- 
ceps and gently incised, so as merely to nick it. The intestines drop 
back the moment the smallest opening in the peritoneum is made, and 
then the incision can be boldly enlarged upward and downward to 
both extremities of the incision. In enlarging the incision the ope- 
rator should always glance through the peritoneum which is lifted 



THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. 79 

up by forceps, to assure himself that he is not opening an abnor- 
mally high bladder. 

The bleeding from the walls of the incision, although stimulated 
by the massage given in scrubbing the skin just previous to the 
operation, is usually slight, and ceases spontaneously, as a rule. If 
too free, one or more vessels may be caught with artery forceps, 
which can be removed at a later stage of the operation, when the 
bleeding will have ceased. Occasionally a large spouting artery 
requires immediate ligation with the finest silk or catgut ligature. 
If the incision proves too small, it may be quickly enlarged by 
cutting upward with a pair of scissors rounded on the points, 
guided by a finger within the abdomen, which protects the viscera 
from injury. 

In making a long incision it is best to cut a little to the left 
of the umbilicus and then upward to the left of the median line, 
thus avoiding the suspensory ligament of the liver. 

Closure of the Abdominal Incision. 

The incision should be closed by two or three rows of sutures ; 
one continuous suture of fine silk uniting the peritoneum, trans- 
fixing each side three or four times to the inch. "The peritoneal 
surfaces thus sutured unite rapidly, and shut off the abdominal 
cavity from contamination by stitch-hole abscesses. Immediately 
overlying the peritoneum are the recti muscles, and over these, 
often a little retracted from the margins of the wound, the strong 
fibrous fasciae. These may now be approximated by a layer of 
interrupted, buried sutures, about three to the inch, taking great 
care to bring together the edges of the fasciae of the two sides from 
top to bottom of the wound. This is the most important step in 
the closure, as in this fascia lies the strength of the abdominal wall, 
and in its proper reunion lies the protection against a ventral hernia 
which, may arise as a sequel to the operation. 

The interrupted sutures should be drawn sufiiciently tight to 
hold the parts snugly together, but never tight enough to constrict 
the tissues. The sutures should then be cut close to the knot. The 
approximation of the skin may be secured either by an interrupted 
silkworm-gut or a continuous fine silk suture, entered below the 
lower angle of the wound, passing from side to side subcutaneously, 
and reappearing above the upper angle. 

Another simple and satisfactory method of closure where the 



80 AN AMEBIC AN TEXT-BOOK OF GYNECOLOGY. 

walls are thin, 'w>, first, to apply tlie continuous peritoneal suture; 
and, second, a series of interrupted silkworm-gut sutures about one- 
third of an inch apart, each including skin, fascia, and muscles. 
The gaping skin between these sutures is approximated by super- 
ficial sutures of fine silk. 

Deessing the Wound. 

The skin is dried and a fine powder of boric acid and iodoform 
(7 to 1) is sprinkled abundantly over the wound ; over this a rect- 
angular piece of several layers of gauze is laid, overlapping the 
incision three or four inches on all sides. The outer edges of this 

Fig. 84. 




Occlusive Dressing of Abdominal Wound. 

gauze are sealed to the skin with collodion. The centre is left dry 
to absorb any discharge from the incision. 

The gauze is freely powdered again, preventing the collodion 
from adhering to the superficial dressing, the abdomen is padded 
out with sterilized absorbent cotton, a many-tailed bandage is ap- 
plied and the patient transferred to her bed. 

Another simple and effective method of dressing, is, first, to place 
half a dozen layers of sterilized gauze over the incision, then a pad 
of absorbent cotton covered with sterilized gauze, large enough to 
cover the abdomen, and the whole held in place by means of a 
six-tailed bandage. 



MENSTRUATION AND ITS ANOMALIES. 



Menstruation. 

Definition. — The flow of the menses. A periodic function of 
the female generative organs, consisting in a bloody discharge from 
the uterus. It occurs, on the average, every twenty-eight days, and 
continues from one to six days. Menstruations extend over from 
thirty to thirty-five years of woman's life, and this time is known 
as the period of the '^genital life.'' 

Synonyms. — It is popularly known by the following names or 
expressions: "being unwell," "periods," "turns," "courses," "flow- 
ers," "terms," "sickness," "the reds," "menstrual flux," "troubles," 
" monthly illness," "the flow," " the catamenia," "the monthly puri- 
fication." 

Regularity and Duration. — The average time of the reap- 
pearance of menstruation, counting from the beginning of one 
period to that of the succeeding one, is twenty-eight days. This 
interval is not fixed ; it is very elastic. In many cases it is less 
than twenty-eight days ; in others, longer than four weeks, appear- 
ing however with punctuality. One woman may menstruate every 
calendar month or twelve times each year, while another may men- 
struate sixteen or seventeen times each year, yet both may be normal. 
Again, a woman may always have irregular intervals between her 
flowing and yet be perfectly well. A woman in good health, who 
asserted that her menses always appeared regularly, was directed to 
keep an accurate record of the intervals for one year. At the end 
of that time her report showed that they varied from twenty-four to 
thirty-five days. Being healthy and never having had her atten- 
tion directed to the matter before, she had always called herself 
regular. The general rule, however, is that women menstruate 
every twenty-eight days. 

Occasionally the menses appear at very irregular periods — e. g. 
two to five times in one year. One woman, in apparently good 
health, gave a history of an average of only two menstruations 

6 81 



82 AJSr AMERICAN TEXT-BOOK OF GYNECOLOGY, 

annually for over seventeen years, her flow having no regularity ; 
the two periods sometimes occurred within thirty days, no other 
menstrual flux appearing till the following year. Such cases are 
altogether unusual. A few women have been known to menstruate 
only in warm weather. 

A normal menstruation may last from one to six days. Each 
woman is a rule unto herself in the matter of the duration of her 
monthly flow. Whatever her experience in this direction may 
be when she is in an otherwise healthy condition, is normal for 
her — a condition that cannot necessarily be laid down as the nor- 
mal one for another woman. Three stages characterize the flow : 
1st, the fluid is slimy and odorous, colored light or dark red by a 
small number of blood-corpuscles in a proportionately large amount 
of mucus ; 2d, the fluid is almost pure blood ; 3d, the fluid becomes 
lighter colored, its constituents being similar to those of the first 
stage. Exceptionally, the third stage is followed by another flow 
of pure blood lasting one day, to be followed by a light-colored 
mucus discharge, lasting thirty-six to forty-eight hours. 

Very commonly, in girlhood, the approaching menstruation is 
heralded for two or three years by certain disorders occurring 
with monthly periodicity. It is not at all rare at this age to meet 
with very obstinate symptoms, such as headaches, epileptic fits, 
digestive disorders, or cutaneous affections, for whose treatment the 
usual remedies fail. The writer encountered in a girl of fifteen 
years of age, before the menses had appeared, an attack of facial 
erysipelas which recurred every twenty-eight days for a period of 
fourteen months. For such maladies medical men are in the habit 
of prophesying a cure when menstruation is established — a fact that 
experience verifies. As the time for the appearance of the flow 
draws nigh the nervous system becomes more irritable; there is 
general uneasiness and an alteration of the moral character. Com- 
monly there is much languor, flushing, sensation of fulness, and 
disturbed or unnatural, heavy sleep, these symptoms continuing 
for a longer or shorter period. Immediately preceding the first 
flow there is much pain and weight, with fulness in the head and 
pelvis, and throbbing and swelling of the mammae. Often the dis- 
charge is not at all regular to the month for the first half year or 
so, passing over a month or longer ; yet the usual prodi-omic dis- 
turbances, enumerated above, are found to observe the lunar inter- 
vals quite regularly. In many young women the precursory 



PLATE XI. 



<-♦:• 



Kg. 1. 



Fi cr. 2 . 



,^K 






P*i 



■i\^'cs^'V;,5 









(f-^ 












■CSi 









^'evi. 



-^>-?/ S~-^'( ^'5 ' /"^ 






Fig-. 3. 















'i^M 



'i&^ 






-e*^ 



:i® 



Figr-. ^ 






»^_^^:::%-^ -^t^^^A 



m 



.^Cv.^/* 



.:>,. -—x ::mV 












v:^:.^' 






•^S^Sw*^. 



^nj^)V' 



Fia^. 6. 






Fig-, b 












8SI^ 



Fi 



^- 7- 



/ 



0® "'" ° 



e: 



^1> 



\. =.i>^ 



Microscopic view of Menstrual Fluid at different periods of Menstruation (Figs. 1, 2, 3, 4). Fragments 
of Endometriuiii cast off ten days after Menstruation (Figs. 5, 6,1). 



MENSTRUATION AND ITS ANOMALIES. 83 

phenomena above mentioned are so slight or evanescent that no 
attention is paid to them. Slight choreic movements and an ele- 
vation of temperature may accompany the first menstruation. 

The menses usually appear in American women at the fourteenth 
year. The colder the climate the later does menstruation become 
established. The average time of its aj^pearance in temperate cli- 
mates has been set at between twelve and eighteen years, from 
thirteen to twenty-one for cold climates, and from eleven to fifteen 
for hot climates. City girls menstruate earlier than girls who live 
in the country. Brunettes are said to menstruate earlier than 
blondes. Precocious menstruation is often seen at ten, nine, and 
even as early as eight years of age. Cases of much earlier appear- 
ance have been frequently reported. One case is recorded in which 
the menses appeared within the " first few months after birth " 
(Charpentier) . On the contrary, there are women in whom men- 
struation is delayed. 

Mei^opause, or Change of Life. 

Definition. — The cessation of the menses is called the " meno- 
pause." By the term is meant that period in a woman's life when 
she stops menstruating. 

Synonyms. — Its synonyms are the " critical time," the " turn," 
the " change of life," the " dodging-point," and the "' climacteric." 

Description. — The menopause includes a very elastic period of 
time in a woman's life. It may be very brief and abrupt, or it may 
extend over a long period of time, as three or more years. The 
typical development of the menopause consists in the irregular 
occurrence of the menstrual flow. Instead of appearing at the 
usual time, it will be delayed a few days or will pass over to 
a second period or longer, and then occur about as usual in the 
amount of the flow and accompanying symptoms. This menstrua- 
tion will be followed by similar irregularity, or perhaps by one or 
more flowings, regular as to the intermenstrual interval and to the 
amount of the discharge and with the usual accompanying symp- 
toms. This irregularity of the discharge may continue for a period 
of over one year, or to three, or even ^yq years, when the flow 
disappears entirely, never to be seen again. 

Occasionally it happens that women, menstruating regularly, 
almost to the day, experience a sudden and complete disappearance 



84 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

of this function. Such an experience in the change of life is 
altogether exceptional. 

The menopause may be said to include all of that period of time, 
intervening between the beginning irregularity of menstruation and 
the complete cessation of the flow, with the subsequent restoration 
of health. At this time the vague nervous symptoms which accom- 
pany the disturbances incident to the change of life are ushered 
in. Where these exist, depending upon the approaching menopause, 
they must be included in this period. During this space of time, 
very often, different symptoms are produced by different women. 

These symptoms include manifestations or perversions, especially 
of the nervous system, and are shown in the form of vertigo, faint- 
ness, flushes, cold hands and feet ; in the digestive system, by gastric 
fermentative dyspepsia, tympanites, constipation or diarrhea; in 
the circulatory system, by palpitation, syncope, and vicarious hem- 
orrhages; in the cutaneous system, by sudden, severe and often- 
times offensive sweatings ; in the mental realm, by loss of memory, 
irritability of temper, fear, apprehension, melancholia, and hysteria ; 
by changes in the physique, the development of hair on the chin 
and face, flaccidity of the breasts, and the great increase of omental 
and abdominal fat. Very many other symptoms might be men- 
tioned. Pelvic and lumbar pains, such eruptive conditions of the 
skin as appear at the age of puberty, pruritus vulvae and colic, are 
often encountered. 

A sallow, chlorotic, or plethoric state, or a nervous condition 
entirely unusual in the patient, may characterize her at this period. 
Leucorrhea is one of the most common symptoms during the 
change of life. An awakening of sexual desire, quite unknown 
during previous years, which is often looked upon with a sense of 
shame and degradation by its possessor, is not uncommon in women 
undergoing the menopause. 

It must be distinctly understood that the symptoms enumerated 
above are not all to be found in every woman at the change of 
life. They include the principal disturbances observed at this 
time in a large number of women. The ones most commonly en- 
countered are the manifestations exhibited by the nervous system. 
The one symptom of all those enumerated that seems to be well- 
nigh universally experienced at this period, is flushes ; few women 
escape them. Next to them in frequency may be mentioned the 
disturbances of the alimentary tract. 



MENSTRUATION AND ITS ANOMALIES. 85 

Some women experience a multitude of these symptoms, while 
others seem to escape nearly all of them. Their cause would 
seem to reside in the sudden congestions of certain areas of the 
nervous system, through the non-escape of the customary monthly 
bloody discharge. Their relief is often experienced by vicarious 
hemorrhages from the nasal mucous membranes, from hemorrhoids, 
by a free diarrhea, or a profuse leucorrhea. 

The sudden cessation of the menses is frequently associated with 
an abrupt invasion of the nervous system, as fright, shock — mental 
or moral — or by some septic malady, as uterine and tubal disease, 
the essential fevers, gout, or rheumatism. 

The symptoms accompanying artificial menopause following the 
removal of the uterine appendages are usually more abrupt, lasting 
in most cases not longer than a year. Consequently, the change 
is more stormy, all the symptoms being exaggerated. 

A stormy, irregular, or delayed menopause should excite in the 
attending physician the suspicion of some pathological condition. 
This is the time of a woman's life when malignant disease of the 
uterus or its appendages is most likely to manifest itself, and usu- 
ally, the first indication that there is any abnormal condition, is seen 
in the behavior of the establishment of the menopause. When 
this has once become established, all the tissues being healthy, there 
should never be a return of the bloody show. Not only should 
the periodical bleeding cease, but all vaginal discharges become 
abolished. If uterine bleeding occurs after the establishment of 
this condition, one of two diseases is most likely to be found — 
either fibroma or malignancy, with the chances largely in favor of 
malignancy, especially if the woman be a multipara. In such cases 
the attending physician should carefully exclude these conditions 
by physical and microscopical examinations. 

The importance of carefully watching a woman through this 
stage of her life cannot be too emphatically dwelt upon. It is 
commonly the practice for physicians to attribute all the ills and 
complaints of such a patient to the menopause. If untoward and 
unusual symptoms appear, they must be carefully studied and their 
cause discovered if possible. Whatever pathological condition is 
found must be dealt with as it would be at any other period of 
a woman's life. 

The time of the cessation varies with the climate, to a certain 
extent ; the colder the climate, the later does the menopause occur. 



86 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The average time of the termination of a woman's menstrual life 
is in her fifth decennium. Variations from this, in recorded in- 
stances, extend from the twenty-second to the eighty-second year. 
Such extremes are altogether exceptional and unusual. 

Women who begin early in life to menstruate usually pass the 
"climacteric" late in life. Those who begin late to menstruate pass 
the menopause comparatively early. Exceptions to both these 
statements exist, but they compass the rule in a large range of 
observations. 

Heredity seems not to be free from influence in determining the 
time of the menopause. As the mother was in this particular, so 
the daughters are very apt to be. Compliances with this rule 
are infinitely more numerous than are the exceptions. 

Pathology. — The involutional changes in the pelvic organs at 
the menopause are precisely the reverse of what is seen at puberty. 
The vulva becomes flattened and shrivelled through absorption of 
its subcutaneous fat. The dimensions of the vagina become con- 
tracted in every direction, and, in the majority of women, the hour- 
glass contraction is seen at the junction of the middle and upper 
thirds of this canal. The uterine walls atrophy, the cavity dimin- 
ishes, and the cervix contracts greatly, sometimes almost disap- 
pearing. The Fallopian tubes diminish in size in all dimensions 
and even become obliterated. The ovaries shrivel and shrink in 
every diameter, even to the point, apparently, of their complete 
disappearance. Their envelope becomes wrinkled and folded in, 
contracting and pinching the walls of the Graafian follicles, which 
appear as little grayish pouches. The mammary glands shrivel 
and become greatly flattened in the majority of women. 

DiAGis^osis. — It is an easy matter to make a diagnosis of the 
menopause. There is one pathognomonic indication of the pres- 
ence of this condition which is invariably found in all cases. If 
every disease or condition requiring the skill of a physician had 
but one symptom as clearly pathognomonic as the climacteric pos- 
sesses, the practice of medicine would be infinitely easy. In all 
cases of the change of life this one indication, never absent, is the 
interruption to the regular and stated appearance of the menstrual 
flow. This interruption does not always present itself in the same 
manner. It usually appears in lapses, of greater or lesser degree, in 
the appearance of the flow. The habit of each woman as to the regu- 
larity of her menstruation must be learned, and from that habit 



MENSTRUATION AND ITS ANOMALIES. 87 

comparison instituted. Women often consult their physicians, sup- 
posing themselves to be passing through this period of their lives, 
so much feared, when inquiry reveals the fact that their menstru- 
ations are perfectly normal in the date of appearance, the amount 
of discharge, and the accompanying symptoms. Such patients, irre- 
spective of their age, can always be assured that the much-dreaded 
period has not yet arrived. 

The symptoms of the climacteric are multiform. The principal 
ones have been enumerated under the description. The test of the 
pathognomonic value of these symptoms is shown by the relief 
experienced by a profuse flow after a protracted amenorrhea of sev- 
eral weeks or months. These flows relieve the congestive state 
which is so productive of perturbed functional conditions. Follow- 
ing them is a cessation of a number of those symptoms that have 
become gradually established during the period of amenorrhea. 

Organic diseases must be carefully excluded in the diagnosis of 
the menopause. For instance, to attribute a pyrosis and vomiting 
to the nervous aspect of the change of life, when an incipient gastric 
carcinoma is present, would be an unfortunate exhibition of diagnos- 
tic carelessness. The most careful and painstaking examination 
should be made in every case. Methodical examination of each 
organ is demanded. In this way only can organic disease wholly 
foreign to the climacteric be excluded. Failure to detect incipient 
pathological developments may result in disaster and death. 

PROGNOSIS. — The prognosis is generally good. Where the germs 
of disease have existed previously, organic disorders may be started 
into activity and developed at this time. This is perhaps especially 
true of dysplasmatic growths. It is frequently observed, in highly 
neurotic women, in whom an hereditary taint of insanity has been 
previously recognized, that this disorder may develop at this time. 

Generally speaking, the prognosis is satisfactory. It is excep- 
tional that the troubles of the menopause are anything more than 
temporarily active. 

Treatment. — The treatment is governed wholly by the indica- 
tions present, and thus becomes symptomatic. 

The axiomatic principle of the treatment of all disorders holds 
true in the management of the menopause, and that is to make 
waste and repair as nearly equal as professional skill will permit. 
This involves a most careful attention to the secretions, the excre- 
tions, and the blood state. Women suffering from a deficiency of 



88 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

secretions, a retention of excretions, or from impoverished blood, 
are sure to present many serious symptoms at the menopause. 

The state of the alimentary tract demands particular attention. 
The fermentative dyspepsias are productive of more symptoms at 
the change of life than at any other period. Gastric lavations, cre- 
asote, salicine, corrosive sublimate, and other antiseptic remedies are 
indicated. A tender liver and chronic constipation call for daily 
laxatives. Cascara, compound liquorice powder, Hunyadi salts, 
Rochelle salts, and other salines are highly useful. The salines 
are especially indicated when anemia is not too profound, because 
their depletory action lessens congestion, an effect greatly needed at 
this period of a woman's life. Daily defecation should be insisted 
upon. Constipation, producing numberless reflexes and leading 
to fecal anemia, is a most deplorable condition and should not be 
tolerated. 

The renal system is to be carefully considered. Renal insuf- 
ficiency must be corrected. Lithemia may be eliminated by the 
free use of lithic-acid solvents, as the citrate of potassium or lithium. 
Lithic acid is the parent of many neuralgias and mucous-membrane 
disorders. Ignoring its presence frequently defeats the physician's 
treatment. 

The cutaneous system should not be ignored. Frequent warm 
baths are useful. Above all, the skin should be protected from 
changes of temperature by suitable underwear. Chilling the sur- 
face of the body facilitates many minor internal congestions, which 
can be avoided by proper attention to the clothing. The systematic 
use of general massage and Turkish baths invites the blood to 
the skin, tending thus to equalize the circulation and to relieve 
internal congestions. 

The condition of the heart demands attention in many cases. 
One of the most common complaints is paroxysmal tachycardia, 
which comes and goes erratically, lasting when present from min- 
utes , to days, the intervals of absence varying similarly. The 
attacks come on without warning, even during sleep, accompanied 
by violent action of the heart, pulsation of the carotids and aorta, 
cephalalgia, and flushes. A consuming fear of apoplexy or sudden 
death prostrates the patient. Her general state becomes demoral- 
ized by repetitions of the attack. Sleep is disturbed by horrible 
dreams, and she becomes the victim of general nervous depression. 
Occasionally oedema without albuminuria is observed. These at- 



MENSTRUATTON AND ITS ANOMALIES. 89 

tacks generally do not depend upon organic cardiac disease, but 
upon local congestion of the heart-centre in the medulla oblongata, 
doubtless a reflex, in the majority of cases, from the alimentary 
tract. This statement is confirmed by the relief following the use 
of remedies addressed to the digestive apparatus. 

All cases complicated with cardiac symptoms demand a most 
careful examination of the heart. Severe and long-continued men- 
orrhagia is often associated with feeble heart. A fatty heart, as 
well as a feeble heart, is attended with impeded circulation, as 
is shown by oedema, albuminuria, dyspnea, and palpitation. It is 
a grave error to attribute such symptoms to nervousness or hys- 
teria or to the change of life. 

The blood state frequently demands attention. Anemia is often 
caused by the dyspepsias and constipation. When it arises from 
hemorrhages, especial attention should be given to the most absolute 
quietude in bed and to hemostatic measures. Blood-poverty is the 
cause frequently of the most annoying and obstinate functional dis- 
turbances of the nervous system ; hence its correction is of the 
utmost importance. Where plethora exists venesection is in many 
cases most urgently demanded. Bloodletting is a lost art to-day ; 
where it is inadmissible, saline cathartics can be freely used. Bleed- 
ing from the arm or from the cervix uteri gives more speedy and 
protracted relief than any other measure; it rarely does harm. 
Leeches can be used over the region of the round ligament at the 
external abdominal ring, or at the anus, in cases of ovarian or uterine 
congestion. 

Mental therapeutics should not be ignored. The depressing 
emotions exert a deleterious influence on woman at this period of 
life. Hence worry, care, anxiety, and unnecessary responsibilities 
should be cast aside as much as possible. Social diversions, amuse- 
ments, and congenial occupations ought to be encouraged. Oppor- 
tunities for depressing introspection should be guarded against 
sedulously. 

The nervous symptoms so common at this time, as flushes, trem- 
blings, headaches, etc., dependent on local congestion of certain areas 
of the nervous centres, are best relieved by the bromides. These 
agents decongest and benumb, hence their wonderfully satisfactory 
action in women passing through the change of life. The eflects 
of these preparations cannot be too highly praised. The choice of 
a bromide is not altogether inconsequential. The ammonium bro- 



90 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

mide is very speedy in its action, but it is far too evanescent. Tlie 
potassium bromide is much slower and more permanent in its effect, 
but its depressant influence on the heart in large doses is objection- 
able. All potassium salts in full doses are cardiac depressants. A 
more pitiable combination than a woman suffering from severe 
nervous manifestations in the menopause, combined with an induced 
cardiac debility, is difficult to imagine. The sodium bromide is 
the best of all bromides to use. It is markedly diuretic and does not 
materially depress the heart. The tendency of the bromides to pro- 
duce acne can be largely averted by the use of arsenic, in the form of 
Fowler's solution, after meals. The effects of the bromides are won- 
derful in relieving pains, flushes, nervousness, and mild melancholia. 
Used in combination with camphor, their anaphrodisiac action, where 
needed, is most gratifying. Too much caution against the miscella- 
neous use of narcotics and diffusible stimuli cannot be entertained. 
The use of opium and chloral is especially objectionable, unless 
the suffering becomes unendurable, when they should be used for 
the briefest period of time and interdicted by the physician's 
specific ordering. The objection to their use is the fear of estab- 
lishing the opium or chloral habit at this impressionable time, when 
a woman will resort to anything to secure relief, irrespective of 
consequences. 

From the foregoing remarks it will be seen that the object of 
therapeutic attack must be sought for, chiefly, outside of the pelvic 
organs. It is understood that uterine, tubal, and ovarian con- 
gestions, when found, are to be treated secundum artem. The 
remainder of the treatment of women at the climacteric is purely 
symptomatic. There is no specific treatment of the menopause. 

Composition arid Quantity of the Menstrual Discharge, — The 
flow at first is mucous in character, gradually changing color till 
it becomes distinctively sanguineous. It has an acid reaction from 
phosphoric and lactic acids ; a peculiar odor, due to fatty acids ; and 
consists of blood (venous), serum, ciliated vaginal epithelium, and 
the debris of an endometrium necrosis, mixed with pigment, broken- 
down blood-disks, and granular detritus. It is ordinarily non- 
coagulable, owing to the mucus that it contains. When there is 
disproportionately too large a quantity of blood present, as in men- 
orrhagia, coagulation is common. Hence, when w^omen flow too 
freely, as from a diseased condition of the pelvic organs, it is exceed- 
ingly common to see coagula discharged ; therefore, the attempt to 



MENSTRUATION AND ITS ANOMALIES. 91 

prove that coagula in the menses indicate an abortion is fallacious. 
At first in normal women the discharge is pale, at the height of the 
flow, deep red, and toward the last, again pale. In chlorotic women 
is seen the pale flow, or menstruatio alba. It is erroneous to say 
that the discharge is poisonous, having an injurious effect on living 
things, as men, animals, and plants. Its mucous element possesses 
at times an injurious and irritating effect on the male urethra, 
causing a peculiar chronic urethritis. One can but be impressed 
by the wisdom of the Mosaic edict forbidding cohabitation with a 
menstruating woman. 

Some women are said to be free from the function of menstrua- 
tion. Close inquiry, however, usually reveals the fact of a periodic 
white discharge occurring from their genital organs. 

The am^ount of the discharge varies from four to eight ounces. 
The recorded observations of extremes vary from two to eighteen 
ounces. Many conditions cause variations in the amount in the 
same women, as health, diet, exercise, climate, and sexual excesses : 
consequently there is nothing fixed. Hippocrates tliought the 
Grecian women shed twenty ounces at each period. Galen averred 
that the Romans lost eighteen ounces. Meigs stated fifty years ago 
that many healthy American women lose twenty-one ounces as the 
normal and regular elimination. Such amounts must be regarded 
as far above the average. 

The source of the menstrual discharge is the endometi'ium. It 
is the consequence of hyperemia of the pelvic organs : the uterus, 
tubes, ovaries, and broad ligaments. The contraction of the mus- 
cular fibres of these organs compresses the veins, retarding the flow 
of blood and increasing the tension in the capillaries, which rupture 
and give rise to the appearance of the menstrual flow. Under the 
influence of this congestion, the volume of the uterus increases a 
quarter, a third, and sometimes more. At this time the pampini- 
form plexus becomes so distended that in lean women it can very 
often be detected by conjoined manipulation. The turgid uterus 
undergoes a true anorthosis. The cervix becomes larger and softer. 
The endometrium swells, becoming folded and mammillated. The 
epithelia become loosened and pushed off. The hypertrophied 
mucous glands become the seat of an abundant secretion. The 
lining membrane of the fundus yields the largest part of the cata- 
menial discharge, because of its looser anatomical texture, while the 
cervical canal, having more resisting vessels, which do not burst, 



92 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



Fig. 85. 




Vertical Section through Normal Mucous Membrane of the Uterus: e, columnar epithelium, the cilia not 
represented ; gg, utricular glands ; ct, ct, connective tissue ; vv, blood-vessels ; mm, muscularis mucosae. 

yields a purely mucous discharge. The canals of the tubes are some- 
times filled with blood likewise, thus increasing the menstrual flow. 
The vagina becomes darker in color and the increased vascularity 
causes the mucous membrane to swell and to shed an increased 




Menstrual Endometrium. 



MENSTRUATION AND ITS ANOMALIES. 93 

amount of mucus, having more or less odor. The vulva often 
becomes tumefied, and is sometimes the seat of mild pruritus, thus 
explaining the frequently experienced micturition. 

The menstrual discharge, composed of blood, mucus, serum, 
epithelia, and the debris of granular detritus, is a very complex 
fluid. The endometrium, undergoing rapid degeneration, is shed 
in patches and shreds. It is called the decidua menstrualis. 
This decidua is developed from the upper part of the uterine 
mucous membrane, and does not involve the Fallopian tubes or 
cervix uteri. The shedding and the redevelopment of this 
decidua are matters involving much speculation. It is generally 
conceded at present that it is cast off in fragments — sometimes in 
one or two large pieces. Within a few days it is re-formed, 
and its shedding again repeated. Should conception occur, the 
decidua menstrualis becomes the decidua vera. The decidua men- 
strualis is a very important factor in membranous dysmenorrhea. 

The syndroma menstrualis includes the attendant phenomena 
of a menstruation, preceding and accompanying it. They are both 
general and local. 

General. — The entire glandular system is stimulated. The sudo- 
riparous glands secrete increasedly, and in many women the odor 
of the perspiration becomes characteristically pungent. The bron- 
chial glands secrete more actively. The alimentary secretions are 
increased in many women to such a degree that they are inclined 
to eat voraciously, while many other women have diarrhea at the 
outset of the menstrual flow. Pigmentary deposit under the eyes 
and on the nipples, genitals, face, and neck is common. An 
increased deposit of fat beneath the skin in most parts of the body 
very commonly accompanies the establishment of the genital life of 
woman, and all the contours become more rounded and graceful. 
The volume of blood is augmented and cardiac action and arterial 
tension are increased. Malaise and lassitude supervene. Many 
girls experience a nervousness bordering upon uncontrollability. 
Alternate subjective sensations of heat and cold are often expe- 
rienced. 

Local. — The vulva becomes more prominent and filled out. The 
uterus and vagina enlarge. Pubic and axillary hair appear. The 
mammary glands increase in size and become sensitive, the nip- 
ples grow larger and darker. The pelvis becomes broader. The 
mental changes exhibit the occurrence of sexual desires, by the 



94 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

development of more reserve and the abandonment of hoydenisli 
ways. Increased micturitions, yawnings, cramps, and hiccough are 
common. Hemorrhages occurring at the same time from other parts 
are known as supplemental menstruation. Piles, if they exist, are 
more congested and nsevi are deeper colored. 

Vicarious or ectopic menstruation, or xenomenia, consists of a 
bloody discharge from some other organ than the uterus, either 
with or without a minimum menstrual flow at the same time. 
When the minimum menstrual discharge occurs, vicarious or 
supplementary menses takes place from the lungs, the nose, the 
alimentary canal, or the subcutaneous cellular tissue. Where there 
is no uterine hemorrhage, the vicarious menstruation may arise 
from the lungs, nose, alimentary canal, mouth, the surface of a sore, 
from an erectile tumor, the skin, the conjunctiva, the nipples, the 
gums, the bladder, the ear, or the stump of an ovarian cyst. The 
nose is the most frequent seat of vicarious menstruation. In men- 
strual hemoptysis it is of vast importance to exclude tuberculosis. 
Occurring from the skin, vicarious menstruation is called " hemati- 
drosis " or *' sweating blood.'' 

Retention of menses, or hematometra, is an accumulation of the 
menstrual flow within the uterus, its exit being prevented by a 
defect of formation of the uterus, cervix, vagina, or vulva. Such 
cases may be denominated apparent amenorrhea. At first they are 
regarded as amenorrhea. Much pain characterizes them, and they 
may be regarded as practically to occupy a place between amen- 
orrhea and dysmenorrhea. Every month the patient presents 
painful disturbance centering in the hypogastrium. Cephalalgia 
may occur, with flushing, accelerated pulse, emesis, intestinal and 
vesical disturbance, and leg pains. In a few days these phenomena 
subside, only to reappear in about twenty-eight days. The general 
health at length deteriorates. Sooner or later the abdomen swells. 
A mild degree of sepsis may occur, commonly hastening to a climax. 
Soon thereafter the physician is called to investigate, and an atresia 
is discovered. 

Cases of uterus bicornis have been reported where one cornu was 
patulous while an atresia of the other existed, causing a retention 
of the menses. Deces reported such a case in 1854 wherein rupture 
and a fatal peritonitis occurred. 

Cases of retention may be congenital or acquired. In the former 
there is some congenital defect or some condition acquired in child- 



MENSTRUATION AND ITS ANOMALIES. 95 

hood. In the latter the atresia most commonly follows parturition 
or syphilitic invasion. 

The intermenstrual molimen consists of the presence, in some 
women, of all the discomforts of a menstruation without a bloody 
discharge, occurring midway between two monthly periods. Many 
women experience it in full intensity, while others have it in only 
a slight degree. Oftentimes therapeutic measures are necessary to 
control these intervening pains. 

Menstruation and Ovulation. — Till within a few years these two 
functions were considered as one, the flow being regarded as the 
external manifestation of ovulation. At present this view is opposed 
by many writers. Formerly no one felt disposed to question the 
accepted theory that the ovaries controlled menstruation. After the 
removal of the ovaries became a common operation, it was found 
that nearly all women undergoing this procedure ceased menstruat- 
ing, and then the conclusion was confirmed that the ovaries pre- 
sided over the function of menstruation. Later it was observed 
that occasionally a woman was found who continued to menstruate 
after oophorectomy. This led to questionings which threatened to 
uproot the time-honored theory of the interdependence of menstrua- 
tion and ovulation. Very soon thereafter one prominent laparoto- 
mist boldly announced his belief that the Fallopian tubes controlled 
the function of menstruation, his argument being, that when the 
ovaries and tubes were completely removed, menstruation never 
appeared thereafter. He thus explained that menstruation after 
oophorectomy occurred because not all of the tubes was removed. 
In time it was found that even after the removal of ovaries and 
tubes cases of menstruation or of monthly flow were occasionally 
reported ; hence the true explanation of the cause of menstruation 
seemed not to have been supplied. Further speculation followed. 
The latest theory of causation advanced, is, that neither the ovaries 
nor the tubes control menstruation. Instead, it is the tubo-uterine 
plexus of sympathetic nerves which causes the appearance of the 
menses. Removal of the ovaries does not always annihilate the 
integrity of this plexus, nor does every case of removal of the tubes ; 
therefore where this plexus remains uninjured the monthly flow 
will continue to appear. Speculation on this much-mooted question 
is still rife. The following statements may be accepted as the status 
of professional opinion on this subject at this time : 1. That ovu- 
lation and menstruation are closely associated, but not necessarily 



96 ^iV^ AMERICAN TEXT-BOOK OF GYNECOLOGY, 

interdependent ; 2. That ovulation may occur without menstruation ; 
3. That conception very often occurs without menstruation. 

Pertinent to the last statement may be mentioned the fact that 
many women go for years without menstruating, while they are 
bearing children in rapid succession and suckling them. One 
case, reported in 1879, showed that a peasant-woman married 
before menstruation began, became pregnant and bore and suckled 
sixteen children in the succeeding twenty-one years, when, at the 
age of thirty-six, she menstruated for the first time. Afterward in 
her widowhood she menstruated regularly. It is claimed that ova 
are developed in the earliest infancy, during lactation, and even after 
the menopause. Evidence has repeatedly been adduced, in reported 
cases, of ovulation occurring during pregnancy. Facts such as these 
supply irrefragable evidence that ovulation occurs without produ- 
cing menstruation. The final settlement of the relation existing 
between menstruation and ovulation is still waiting unassailable 
demonstration. 

Menstruation during Pregnancy. — When a woman is pregnant 
her menstruation does not appear ; that is a rule, to which, how- 
ever, there are exceptions. The exceptions are atypical : some 
women menstruate once after conception, some twice, and others 
oftener. Whether the flux is a pure and simple menstrual flow 
has perhaps been questioned, but the fact is indisputable that it 
has appeared promptly on time and has acted just like a genuine 
menstrual flow. Such discharges of blood have been called " acci- 
dental hemorrhages," and not the typical bloody flow of menstrua- 
' ation. The writer recalls a woman whom he has attended in five 
out of her six confinements, in whom the calculation of the time 
of her delivery was always computed from the date of quicken- 
ing, it being impossible to determine when conception occurred, 
because she always had her monthly flow up to the fifth month 
of gestation. 

The decidua vera and the decidua rejlexa do not coalesce and 
occupy the entire uterine cavity till the end of the third month of 
gestation. Till that time it is easily understood whence arises the 
flow — namely, from the uninvaded endometrium. After the third 
month, however, the menstrual flow must arise from the cervical 
canal, and it will be small in quantity^ — a fact which comports with 
observations. These remarks in no way apply to cases of bloody flow 
in pregnant women who have uterine cancer, an inflammatory or 



MENSTRUATION AND ITS ANOMALIES. 



97 



congested cervix, a polypus or cardiac disease, nor to cases of extra- 
uterine pregnancy. Cases are related in which patients habitually 
menstruate only when pregnant. That a woman can menstruate 
and ovulate after fecundation is shown by superfetation. 

Management of Menstruating Women. 

Physicians should instruct mothers to secure rest and quietude 
for the girl entering on her menstrual experience. Ignorance of 
this function on the part of the girl is highly culpable in the mother. 
Many a young woman has injured herself irreparably by attempts 
at concealing her flow, supposing it to be something disgraceful. 
Thus, washing in cold water, in brooks and streams, has been done 
to conceal a supposably shameful condition. 

Fig. 87. 




Menstrual Pad. 



Where it is practicable the young woman should remain in bed 
two or three days or longer during her menstruation. She is the 
better for such enforced quietude and freedom from the usual wear 
and tear of her nervous energy, incident to active youthfulness, 
at a time when her system is learning to accommodate itself to a 
new experience. Books, magazines, and pictures can entertain her 
during these days of restraint. She becomes accustomed to the 
monthly quietude and accepts it without a murmur. Every woman 
is better off for such resting, and it should, whenever possible, be 
secured for girls, during the first year, at least, of their menstrual 
life. Where it is impracticable, her duties should be rendered as 
light as possible, and everything in the way of severe exertion 
should be avoided. It is, unfortunately, only too often the case 
that no rest nor lessening of arduous duties can be secured to 
young women. Such women grow old too soon. 



98 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Amenorehea. 

Definition. — Amenorrhea is the absence of the menses in 
adult women who are not pregnant, have not passed the meno- 
pause, or do not suffer from retention of the menstrual flow. It 
is not, per se, a disease. It results from a variety of causes 
which may affect either the system at large, or the genital organs 
in particular. Thus we may have amenorrhea resulting from 
general as well as from local causes. 

Complete amenorrhea is the total absence of menstruation, whereas 
comparative amenorrhea is that condition in which the menstru- 
ation appears only occasionally. Primary or permanent amenor- 
rhea is the expression used to describe cases wherein menstruation 
has never occurred. Secondary, transitory or accidental amenor- 
rhea has been called suppressio mensium. 

Causes. — To simplify the causation of all amenorrheas the 
etiology may be reduced to the following : 

Normal menstruation requires the following conditions : 

1. A normal condition of the nervous system ; 

2. A normal state of the blood-supply ; 

3. Integrity of the entire genital apparatus. 

With these three conditions in existence a woman will menstru- 
ate normally and regularly. Serious interference with one or more 
of them will produce amenorrhea. 

The nervous system presides over all functions of the body. 
When it is disordered seriously, the functions are in turn seriously 
disordered. Menstruation must be regarded as a reflex act. Any 
break or interference in the cycle of the reflex movement may 
suspend the menstrual flow entirely. Hence amenorrhea may 
arise through defects in the nervous system. 

It is almost unnecessary to state that there must be enough good 
blood present in the system before a woman can menstruate nor- 
mally. Its absence is one of the most prolific causes of the cessation 
of the flow. 

That the entire genital system must be in a normal condition to 
permit menstruation is self-evident. The organs must all be pres- 
ent, free from stenoses and from degenerative structural changes. 
In enumerating the following causes of amenorrhea it will read- 
ily be observed that each bears upon one or more of the three 
conditions. Therefore, bearing them in mind will enable the stu- 



MENSTRUATION AND ITS ANOMALIES. 99 

dent and practitioner to arrange the various causes systematically 
and in order. The popular idea that amenorrhea is productive of 
dangerous constitutional conditions, as consumption, dropsy, chlo- 
rosis, nervous prostration, and the like, will be clearly understood 
to be a reversal of cause and effect. 

Whatever seriously affects the general nutrition may stop the 
menses temporarily. Thus, an attack of typhoid fever or any other 
serious disease may cause amenorrhea for several months. Through 
such illnesses the function of hematosis is impaired, preventing the 
general nutrition of the system. Thus the nervous system with its 
infinite reflexes fails to perform all of its functions. Menstruation, 
doubtless a reflex, shares the neglect whenever the general nervous 
system is not well nourished. The diseases that most frequently 
cause amenorrhea are chlorosis and pulmonary tuberculosis. It is 
produced by the anemia that follows the essential fevers, pneumo- 
nia, Bright's disease, diabetes, morphinism, cancerous or malarial 
cachexia, alcoholism, hydrargyrism, acute or chronic surgical affec- 
tions, and the onset of profound syphilitic invasion. 

Extreme mental emotion, as fright, grief, anxiety, or great anger, 
may suspend the function of menstruation. Women anxious, from 
misconduct, to menstruate, will often fail to do so. Conversely, 
cases of cure by some sudden emotion have been recorded. Pris- 
oners and insane women are often victims. Hysteria gravior is 
frequently characterized by the cessation of the menses. The 
emotional amenorrhea of the newly-married is well known. The 
anxiety of the woman intensely desirous to become a mother will 
cause a cessation of the menses, often accompanied by tympanites. 

Pelvic disorders may cause amenorrhea, as : imperfect or rudi- 
mentary development ; absence of the ovaries or uterus ; cystic 
ovarian degeneration ; pelvic peritonitis with its resultant adhe- 
sions, deforming and displacing the general aspect and position of 
the pelvic organs ; acute metritis and endometritis, chronic diseases 
of the uterine parenchyma and parametrium, and hyperinvolution 
of the uterus following pregnancy. 

Girls who, during the period of active development of the gen- 
erative organs, are urged on in intellectual studies without a suf- 
ficiency of active exercise, fresh air and good healthy hygienic 
surroundings, very commonly suffer from amenorrhea. The 
vis 7iervosa necessary to physical development is perverted and 
expended in mental work, resulting in delayed or imperfectly de- 



100 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

veloped generative organs. Being the last developed, these organs 
are the first to fail in fulfilling their function. 

Great changes in the mode of living often develop this condition. 
Thus, nurses in training-schools at times cease to menstruate for a 
period of two to six months after entering upon their new mode 
of life. There is often a suppression of menstruation following 
a sea-voyage. 

Rapidly increasing obesity with its resultant anemia, insuf- 
ficient exercise, and luxurious living, are all well-recognized causes 
of comparative amenorrhea. 

One of the commonest causes of acute amenorrhea is exposure 
to cold during a menstrual period ; cold bathing, sitting or lying 
in currents of cold air, sitting on cold stone steps, and a change 
of linen, are common modes of such exposure. 

Traumatic injuries can also cause this condition. Nearly every 
physician of experience can recall some case of amenorrhea caused 
by a blow or injury. 

Renal insufiiciency is often a cause. Embryologically, the 
urinary and the generative organs arise from the mesoblast in the 
ovum. It is an easy matter to understand that interruption to the 
physiological action of one set of these fundamental organs may lead 
to the interruption of that of the other. The logical sequence of 
cause and effect, herein, may be assailed, but the therapeutic proof 
is brilliant and incontestable. The writer has repeatedly seen cases 
of comparative amenorrhea, with no other discernible cause than 
renal insufficiency, corrected by the use of stimulating diuretics. 

Diagnosis. — All cases of amenorrhea must be carefully exam- 
ined, even under complete anesthesia. 

First, it should be definitely settled whether the case is pri- 
mary or secondary. Primary amenorrhea, where menstruation 
has never occurred, at once leads to questioning whether the ute- 
rus, tubes, and ovaries be present in their entirety. If present, 
it becomes necessarv to ascertain whether an atresia of the cer- 
vical canal, vagina, or vulva exists. If the prodromic symptoms 
of a menstruation have never been present, the suspicion of the 
absence of one or more of the generative organs will strongly obtain. 
If these prodromic symptoms have been present, repeatedly, at lunar 
intervals, with no succeeding menstrual flow, the suspicion is at once 
excited that an atresia exists, and that the menstrual flow is retained 
within the genital passages. 



MENSTRUATION AND ITS ANOMALIES. 101 

If the case be one of secondary amenorrhea, the cause must be 
sought for both within and without the pelvis, Primarily, preg- 
nancy and lactation must be excluded. Within the pelvis there 
may exist hyperinvolution of the uterus following pregnancy — i. e, 
a senile uterus. Acute metritis, acute endometritis, or an intense 
chronic metritis may be found. There may be atrophy or cystic 
degeneration of both ovaries. Pelvic peritonitis may be present. 
Either one or more of these pelvic maladies may cause an amen- 
orrhea, although the reverse usually obtains in the inflammatory 
conditions. 

Without the pelvis will be found the larger proportion of causes 
of the cessation of the menses. Interferences with hematosis through 
disease and perversions of digestion and nutrition, are the common- 
est of all causes of secondary amenorrhea. A careful and minute 
inquiry as to the anamnesis of this condition will lead to the 
particular line of approach of the causal anemia. This inquiry 
should be particular, systematic, and exhaustive, because without 
it the practitioner will only too frequently fail to learn the cause, 
and consequently to institute the proper treatment. 

After securing the completest possible case-history, confirmation 
thereof will be afforded by a thorough physical examination. Some- 
times such an examination will reveal an organic valvular heart 
lesion, to the astonishment of the physician. If the investigations 
are carried no further the treatment will not include a slowly- 
advancing Bright's disease, for example, which has led to the 
cardiac lesion, and the physician will fail in restoring the menses 
as, perhaps, have other practitioners in the same case. Such physi- 
cal examination should include the entire system; especially the 
thorax and abdomen. Only the superficial observer will confine 
his examination to the pelvis. It is surprising to note how often 
a hydrothorax or a tuberculous kidney will be found as causative 
factors in amenorrhea. The urine should always be analyzed. 
The systematic examiner of his gynecological cases will be aston- 
ished at the discoveries oftentimes in his patients — discoveries that 
have so easily eluded former medical attendants — discoveries that 
shed an entirely new light in the way of cause and effect. 

The PROGNOSIS depends entirely upon the cause. Amenorrhea 
from the absence of pelvic organs is incurable. Pulmonary tuber- 
culosis and other incurable disorders, as advanced Bright's disease 
or diabetes, present a gloomy prognosis. In cases of hyperinvo- 



102 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

lution of the uterus the prognosis is unfavorable. Pelvic inflam- 
mations, amenable to treatment, afford a more promising prognosis. 
In short, only where the cause can be removed is there reasonable 
hope of restoring the menstrual flow. 

Treatment. — It must be borne in mind that many cases of 
amenorrhea exist without producing any kind of disturbance of 
health. The absence of menstruation is simply a part of a con- 
stitutional state. There is no local treatment that will re-establish 
this function. In patients rapidly progressing along the way of 
recovery through general treatment, local treatment will often be 
followed by the restoration of the menses, but this is not post hoCy 
propter hoc. The uterus can easily be made to bleed, but this 
must not be confounded with menstruation. In truth, we cannot 
predict positively in any given case of amenorrhea that our treat- 
ment will restore the menses. 

Our patient must be regarded as an entity possessed of a multi- 
plicity of organs, and any and all treatment must include their 
functions and interdependence. The moment the physician loses 
sight of this general fact, his treatment becomes the merest empi- 
ricism. The fact ought not to be ignored that a remedy given to 
a woman progressively improving under general treatment, and 
who is about to menstruate, will unjustly be pronounced an effect- 
ive emmenagogue when in reality it had nothing whatever to do 
with the restoration of the menses. , It is incontestable that many 
drugs have thus been endowed with a virtue never possessed. 

The cause always determines the treatment. When pregnancy 
exists, no treatment is to be instituted. Upon this point the prac- 
titioner must ever be on his guard. Designing women often con- 
sult the physician for amenorrhea when they know that they are 
pregnant, hoping that something will be done " to bring on their 
courses " and thus interrupt the gestation. In all cases when in 
doubt the physician should either decline to give local examina- 
tions and treatments, or simple tonics may be administered with 
the instruction that the patient return in a month. The patient, 
seeing the object of her desire so far removed, will not call again. 

The necessary anamnesis obtained and examination having 
been made, the point of therapeutic attack will, as a rule, have 
been exposed. Cases amenable to treatment should be treated 
ever and always with the one fundamental object in view — viz., to 
restore the normal physiological balance, and to render waste and 



MENSTRUATION AND ITS ANOMALIES. 103 

repair equal." To this end it is necessary to restore functions where 
needed ; to increase the activity of the skin, kidneys, bowels, liver ; 
to augment the volume of the blood with hematic remedies; to 
improve and invigorate the energy of the general circulation by 
out-door exposure and exercise ; to secure the needed daily regen- 
eration of the nervous power by sufficient sleep, and to protect 
from undue exposure an already enfeebled system by a sufficiency 
of simple and sensible clothing. A gynecologist doing this sort 
of work invades the wide domain of the general practitioner. 

A daily laxative, like the extract of cascara sagrada, or the 
compound liquorice powder, at bed-time, and a tonic after meals, 
as the elixir of iron, quinine, strychnia, and phosphorus, or 
arsenic, or the mineral acids, will be required in the majority of 
cases. If renal insufficiency exists, a stimulating diuretic must 
be added to the laxative and tonic. A good diuretic is the com- 
bination of the potassium acetate with digitalis, or a quarter of a 
grain of calomel, before meals, and the effervescing granular salts 
of lithia citrate or carbonate, after meals. 

With the reconstruction of the general health the menses will 
usually return where no organic perversion or defect remains. 

From time immemorial remedies have been vaunted for restor- 
ing the menses. To-day, with an improved knowledge of the 
pathology of amenorrhea, the number of emmenagogue remedies 
has become greatly diminished. Iron, manganese, and electricity 
enjoy the largest amount of favor as possessors of emmenagogue 
properties. Ergot, rue, savine, and the essential oils are now 
rarely used to restore the menstrual flow. 

The use of iron has been mentioned. The binoxide or lac- 
tate of manganese or the permanganate of postassium, in one-grain 
doses, three or four times daily after food, has found favor as an 
emmenagogue ; it is alleged to determine an increased flow of 
blood to the pelvic organs. Santonine, in ten-grain doses at 
bed-time, has been used with success in chlorotic subjects where 
manganese has failed. 

Electricity has been used to restore the menses by a number 
of gynecologists in the past decade. Its successes and failures do 
not yield the most unqualified enthusiasm in its use. Faradism 
may give gratifying results. Static electricity is commended in 
chloro-anemic girls. The continuous current is used with the 
positive pole over the lumbar or iliac regions and the negative 



104 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

pole in the uterine cavity. Thus applied, it often produces an 
uterine hemorrhage, which is not always a true menstruation. In 
cases where the uterine changes, leading up to a menstrual flow, 
are present without apparently sufiicient menstrual energy to even- 
tuate in a normal periodical discharge of blood, electricity will 
undoubtedly precipitate the desired result. Unable to determine 
positively the presence of such uterine changes in a given case, 
the use of this agent must be more or less empirical. 

Galvanic intra-uterine stem pessaries are oftentimes efiicacious 
in relieving amenorrhea : they consist of alternate beads of zinc 
and copper arranged on a stem. 

Intra-uterine stem pessaries have been successfully employed in 
restoring the menses. The mechanical irritation and cervical dila- 
tation have doubtless contributed to impel more blood to the uterus 
and its adnexa. 

Guaiacum has been strono-lv recommended in amenorrhea in 
subjects of marked rheumatic diathesis. The well-known action 
of capillary stimulation by this drug doubtless accounts for its 
efficacy in restoring the flow. 

The allegation has been made that, as strychnia favors muscu- 
lar contractility, and thus can aid in rupturing the Graafian vesicles 
most advanced toward maturity, it favors ovulation. Its use as an 
emmenagogue in amenorrhea has been favorably reported. 

Sodium salicylate has been successfully employed because of its 
power to produce pelvic congestion. 

Oxalic acid, in half-grain doses three or four times a day, has been 
highly recommended and is very eflective. It has been known to 
bring about a raiscarriage when accidentally given during pregnancy. 

Indigo has recently been very highly recommended in the treat- 
ment of this condition. It cured 13 out of 14 cases ; the fourteenth 
was a failure because it was a case of pregnancy. Under its use the 
OS uteri becomes soft and patulous, admitting the index finger. 

The latest advocated method of treatment of amenorrhea is by 
psychotherapy. Every month brings reports of cures by hypnotism. 
These cures are obtained by the induction of the hypnotic state and 
subsequent suggestion. It is alleged that results truly marvellous 
have been obtained with the expectant attention induced by sug- 
gestion. In the present chaotic condition of the entire subject of 
psychotherapy, the writer is content with barely calling attention to 
hypnotism in this connection. 



MENSTRUATION AND ITS ANOMALIES. 105 

Marriage has been recommended as a suitable stimulant in some 
cases of amenorrhea. In view of the fact that we have no positive 
data upon which to base a prognostic success, such advice is ques- 
tionable ; its failure wauld entail mental misery to both parties to 
the marriage. Whenever we are consulted in regard to the mar- 
riage of an amenorrheic woman, a thorough pelvic examination is 
imperative. Should such a woman marry upon medical advice 
without an examination, she may discover, when too late, that she 
is unfortunately deformed, by the lack of a normal development 
of the generative organs. Such an eventuation has led to more 
than one tragic termination. It has also caused tribunals to declare 
nullity of marriage on the ground of error as to the sex of one 
of the parties. 

Amenorrhea is merely a symptom of some general disease, except 
in those rare cases of malformation, and as such, requires no local 
treatment, nor general treatment directed solely to the pelvic 
organs. In the vast majority of cases it causes no trouble what- 
ever, the patient applying for treatment simply for the reason that 
the usual flow has failed to appear. The mere absence of the 
menses should be ignored, especially when no other symptoms arise. 

Menorrhagia and Metrorrhagia. 

Definition. — The first of these two words is used to express an 
excessive menstruation ; the second, for a flow of blood not only at 
the menstrual time, but between menstrua^ons. Neither condition 
is a disease ; both are symptoms of some well-defined pathological 
condition. The latter may be profuse or moderate. The patient 
who menstruates too freely is said to have menorrhagia, while one 
who sheds blood between the menstrual periods is said to have 
metrorrhagia. Women differ in the amount of the normal flow. 
What would be normal flow in one woman would be hemorrhage 
in another; accordingly, whatever the amount of flow a woman 
may have in health, during the first few years of her menstrual 
life, may be regarded as normal for her. In this particular each 
woman is a rule unto herself. 

Frequency. — Both of these conditions are commonly met with. 
They may arise from many varying conditions. Any reliable attempt 
at the expression of the percentage of women who have menorrhagia 
or metrorrhagia cannot be made. 

Causes. — The numerous conditions causing too great a discharge 



106 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

of blood from the uterus demand most careful inquiry for their 
rational treatment. Each case of hemorrhage should be investi- 
gated independently for its cause. Indeed, all successful treatment 
will depend upon the finding of the cause. Frequently the same 
cause produces the two conditions. When the cause is an aggra- 
vated one it may occasion the continuous discharge of blood — me- 
trorrhagia; during its process of disappearance, under treatment, 
it will be found that the metrorrhagia may be converted into 
menorrhagia, and that, in turn, may give way to the normal men- 
struation when the cause is entirely removed. It will thus be seen 
that it is a particularly difficult matter to differentiate between 
the causes of menorrhagia and metrorrhagia. 

All causes of uterine hemorrhage may be classed under two 
heads, general and local. 

T\\Q general causes involve general conditions, and are the fol- 
lowing : purpura, plumbism, severe icterus, scorbutus, Bright's 
disease, the spanemia of obesity, phosphorus-poisoning, malarial 
poisoning, the early stages of tubercular invasion, cardiac disease, 
and oftentimes, plethora. Hemorrhage may occur in the progress 
of an acute fever. In the majority of the above-named general 
causes, the plasticity of the blood is so diminished that clot-forma- 
tion is seriously impaired, and for that reason the loss of blood 
continues indefinitely. Such patients very often have periods of 
amenorrhea of indefinite duration, alternating with hemorrhages. 

The local causes may be reflex or direct. In the former cate- 
gory actual disease may exist or be absent. Among these cases may 
be classed the hemorrhages incident to puberty and the menopause, 
to the first intercourse, to lactation, and to any powerful emotion. 
The direct causes of all menorrhagias and metrorrhagias are the 
ones that demand our attention in the vast majority of all hemor- 
rhages. They include nearly every disease of the uterus and its 
appendages, as metritis, endometritis, subinvolution, granular cer- 
vix, retained secundines, retro-displacements of the uterus, fibroids, 
cancer, polypi, pressure outside of the endometrium, as from fibroid 
tumors and fecal accumulations, ovarian tumors, chronic ovaritis, 
chronic salpingitis, hematocele, and acute pelvic inflammation. 

Attention is called to another form of hemorrhage from the 
uterus, occasionally seen, where pregnant women shed blood from 
the second to the sixth month without miscarrying, and apparently 
without endangering the life of the child. Speculum examination 



MENSTRUATION AND ITS ANOMALIES. 107 

carefully made fails to reveal the cause. The gestation is not neces- 
sarily interrupted, especially under the conservative treatment, if pro- 
longed rest and quietude and the careful abstinence from too active 
curative measures be observed. Women who have an habitual flow 
at what would be the menstrual period if they were not pregnant 
are not included in this class. The hemorrhage comes on at any 
time, and persists indefinitely, from a day to weeks, without inter- 
ruption, apparently uninfluenced by anything that can be done. 

Pathology. — From the conditions enumerated above it will be 
seen that whatever condition indicates too free a flow of blood to the 
uterus may become the cause of hemorrhage. Any one of these 
conditions existing alone may produce the flow ; with several coex- 
isting conditions the flow is still more certain to appear. Occasion- 
ally violent hemorrhage will be witnessed from the uterus, when a 
careful exauiination will fail to classify the cause. 

Prognosis. — If the cause can be found and removed, the prog- 
nosis is good. If the cause cannot be found, the treatment must be 
symptomatic and the prognosis uncertain. If the cause can be 
ascertained, but cannot be removed, its natural history will deter- 
mine the prognosis. 

Many conditions result from these hemorrhages. We thus have 
general anemia, sterility, extreme emaciation, neurasthenia, wreck- 
ing of the health, and occasionally, death. 

Treatment. — The treatment of uterine hemorrhage is deter- 
mined by the cause. It is not always possible to determine the 
cause ; then it is necessary to treat the hemorrhage empirically. 
The treatment of cases when the causes are known will be taken 
up in order. 

When the causes are general, general treatment is required with- 
out interruption between the hemorrhages. For the treatment of 
these general causes the reader is referred to a work on general 
practice ; therefore no attempt will be made to direct their man- 
agement. 

When a well-defined local cause is discovered, its treatment 
should be outlined according to the directions given for treatment 
in the appropriate article elsewhere in this volume. Thus the 
treatment of metritis, subinvolution, cancer, chronic salpingitis, 
retained secundines, and fungosities of the endometrium will be 
found fully described under the appropriate headings. 

For the emergency of hemorrhage the number of remedies rec- 



108 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

ommended in the past is very large. First of all, the patient 
should be put to bed, and compelled to remain in the horizontal 
position, with the hips and lower extremities elevated. The more 
severe the hemorrhage the more imperative is this measure. It 
will oftentimes be found that a hemorrhage nearly stopped will 
be brought back in all its fury upon the patient's arising from 
the bed to answer, for instance, the calls of nature. Cold applied 
to the lumbar and sacral regions contributes to diminish and check 
hemorrhages. In very severe cases of uterine hemorrhage, cording 
the arms and legs close to the body will be found of service : by 
this means large volumes of blood will be kept in the extremities 
for a sufficient length of time to permit clotting of the blood in 
the openings of the blood-vessels within the uterus. 

Of remedies used internally, the following may be mentioned : 
ergot, in twenty-drop doses, frequently repeated by the stomach, or 
in drachm- or two-drachm doses, with a drachm of deodorized tinc- 
ture of opium, by the rectum ; ergotin given in pill form, or canna- 
bis indica, given to the point of producing mild hallucinations. 

Various vegetable astringents containing tannic and gallic acid 
as their base, as catechu, kino, and hematoxylon, have been recom- 
mended. 

The mineral astringents, like alum, iron, and lead, have also been 
used. 

In the moderate, persistent, erratic hemorrhages occasionally 
observed in parturient patients, digitalis is perhaps the best remedy 
that can be suggested. It operates by increasing the arterial ten- 
sion, thus diminishing the amount of blood going to the part suffer- 
ing the hemorrhage. Ergot in such cases is to be avoided for fear 
of interrupting the pregnancy. Hydrastis canadensis, quinine, 
hamamelis, strychnine, and especially atropia, are remedies that 
have been used to control hemorrhage in the non-pregnant uterus. 
Atropia is administered in doses of to7 of a grain three times daily 
for several days, or in smaller doses if the patient be very susceptible 
to the drug. These drugs are all alleged to exercise an influence 
upon the uterine muscles. Oil of erigeron and oil of cinnamon are 
at times effective where other remedies fail. 

Mineral acids have been recommended. The dilute sulphuric 
acid is the safest and best. 

Treatment between Periods. — Women anemic from hemorrhage 
must be treated with tonics, protected from fatigue, and placed in the 



MENSTRUATION AND ITS ANOMALIES. 109 

best general hygienic conditions regarding rest, fresh air, and sleep. 
Due attention should be paid to the secretions and excretions. 
The marital relations are to be avoided. 

In very severe cases of hemorrhage, where the action of medicines 
cannot be awaited, immediate resort to mechanical measures is 
imperative. Accordingly, one or more sponge tents should be 
inserted in the os uteri, and a firm tampon of iodoform gauze 
placed beneath. In such cases immediate and urgent attention to 
the general condition of the patient is demanded as to food, stimu- 
lants, and absolute quietude. The tents and the packing should 
be removed within twenty-four or forty-eight hours, during which 
time some anti-hemorrhagic remedy must be used. 

Objection is made in many quarters to the use of sponge tents 
for fear of producing sepsis. But in the sponge tents of to-day, 
impregnated with carbolic acid or other antiseptics and imperme- 
ably covered with gelatin, we have an agent superior to the iodoform 
gauze recommended for intra-uterine packing. The tents are asep- 
tic and constitute a much more reliable barrier to the escape of 
blood from the os uteri. However, tamponing the endometrium 
with iodoform gauze is very often efficient in these cases. Occa- 
sionally, in especially spanemic patients, an oozing hemorrhage will 
continue through the iodoform-gauze tampon — a thing that is not 
likely to occur when sponge tents are used. 

Hot vaginal injections oftentimes control hemorrhage. They 
should be exceedingly hot and their use protracted. The effect of 
the heat is to produce a stimulation of the vaso-motor constrictor 
nerve, thus closing the blood-vessels contributing to the hemorrhage. 

It has been recommended, in cases of profuse menorrhagia occur- 
ring in slender, anemic women, to resort to tamponing the vagina 
at each menstrual period for several consecutive months — a pro- 
ceeding that does not stop the menstrual flow entirely, but which 
seems to do away with the excessive loss of blood. Should the 
amount of blood be still excessive and exhausting, in spite of the 
vaginal tamponing, no hesitation need be had in resorting to uterine 
tamponade. Under this treatment women frequently regain their 
color, strength, and flesh. 

In cases of hemorrhage from lacerated cervix or cancer in the cer- 
vix uteri, the use of the persulphate of iron, with iodoform or boracic 
acid, is an excellent treatment. Where these fail vaginal tampons 
may be relied upon. 



110 ^iV^ AMERICAN TEXT-BOOK OF GYNECOLOGY, 

Dysmenorrhea. 

Definition. — Dysmenorrhea means painful menstruation. Nor- 
mal menstruation is painless. A mild degree of discomfort and 
uneasiness experienced by many women is not included in this dis- 
order. Many women suffer pain during menstruation upon moving 
around, but are free from it while lying down. Women experienc- 
ing mild suffering only can scarcely be included under the head of 
dysmenorrheic patients. 

Description. — The different manifestations of pain in dysmen- 
orrhea are very numerous. Some women experience pain until the 
flow is fully established, when all suffering ceases. Others have the 
prodromic suffering, which extends through to the second day of 
the flow. Others have the prodromic pain and that of the first 
day or two, to be followed by complete relief for a time, when it 
will again reappear during, for example, the last day of the flow. 
With some the pain occurs suddenly with the flow, extends through 
the whole period, and gradually disappears as the flow ceases. 
Again, other women have painful menstruation every second month, 
having no pain at the alternate period. 

The seat of the pain varies in different women. In the vast 
majority, the pain occurs in the hypogastric region ; in other cases 
it invades both the hypogastric and iliac regions. In still other 
cases it is circum-pelvic, starting from the lumbo-sacral region. 
Still other women have the pain located in one iliac region only. 
In severe cases it extends down one or both legs or up to the waist, 
or even to the axilla. 

In the vast majority of cases of dysmenorrhea the pain is not 
severe enough to demand the attention of the physician, quietude 
and domestic remedies sufficing to relieve the suffering. Some 
cases are so severe as to demand medical interference. In the 
severest cases the general health is undermined, the nervous 
system yielding the most urgent manifestations, such as hysteria 
gravioVy mania, and even epilepsy. One case came under the wri- 
ter's observation many years ago, where it was necessary to perform 
artificial respiration for several hours during the flow. Some cases 
are so intractable as to defy remedial measures, necessitating the 
operation of oophorectomy. 

A certain phenomenon occasionally observed has been denomi- 
nated intermenstrual dysmenorrhea. It is characterized by spas- 



MENSTRUATION AND ITS ANOMALIES. Ill 

modic pains in the iliac regions, occurring in the interval between 
the menstruations. It is only occasionally met with, is rebellious 
to treatment, and has been so severe as to demand the removal 
of the ovaries for its abolition. 

In one form of dysmenorrhea the pain is slight in the beginning, 
and progressively increases until it reaches a climax, suddenly 
terminating in a gush of blood from the vaginal orifice. It is fol- 
lowed by a period of comparative relief from pain, which, in a few 
minutes or an hour or two, is succeeded by another similar parox- 
ysm of suffering. This variety is seen in many cases of uterine 
flexions. It has been characterized, perhaps erroneously, as tubal 
colic. 

Varieties and Pathology. — Writers have described many 
varieties of dysmenorrhea. While the tendency of this sort of 
teaching, unqualified, may be misleading, it is perhaps best to sub- 
divide the subject into varieties for convenience of description. 
Above all, it must be borne in mind that dysmenorrhea is always 
a symptom of some pathological condition which utterly precludes 
the possibility of routine treatment. Indeed, any attempt to treat 
all cases alike is the merest charlatanism. The names given to 
express the different varieties of dysmenorrhea imply the leading 
pathological conditions. It must be understood that one or two, 
or even three, varieties of causes may be found in the same patient ; 
therefore it is possible for one patient to have one or more varieties 
of dysmenorrhea, just as any person may have one or two or three 
different kinds of headaches. It will be seen that the completest 
examination of each case is absolutely necessary in order to intelli- 
gently institute treatment. Like amenorrhea, menorrhagia, and 
metrorrhagia, this condition is merely a symptom, not a disease. 
The following varieties have been described by authors : 1. Neu- 
ralgic ; 2. Congestive ; 3. Mechanical ; 4. Ovarian ; 5. Membranous. 

1. Neuralgic. — This variety may not be associated necessarily 
with any disease of the pelvic organs. It manifests itself chiefly 
in the class of patients of the nervous or neuralgic temperament. 

Causes. — Any constitutional condition which tends to develop 
the neuralgic disposition, as anemia, chlorosis, gout, rheumatism, 
syphilis, malaria, and the like, will precipitate neuralgic dysmen- 
orrhea. This form of the complaint includes cases from the 
very lightest to the very gravest variety. 

2. Congestive. — During menstruation the pelvic organs are 



112 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

congested. When it is normal no pain exists. Wiien there is a 
state of chronic inflammation, or distorting and deforming adhe- 
sions from pelvic inflammation, the normal congestion becomes an 
abnormal one, and pain results, constituting what is known as con- 
gestive or inflammatory dysmenorrhea. Even in conditions of 
chronic endometritis the menstrual congestion is sufiicient to pro- 
duce this form of dysmenorrhea. The various forms of tumors, 
as fibroids and polypi, can also constitute a cause. 

This form of the malady is seen most frequently in women who 
have borne children or have aborted, and in women who began the 
menstrual life and maintained it for a given length of time without 
pain. It is the variety which is nearly always traceable to some 
disorder of which the patient will give the history. 

3. Mechanical. — In this class of cases there is some obstruc- 
tion to the ready outflow of the menstrual fluid. It can come from 
a great variety of conditions. It may occur from stenosis of the 
cervical canal, produced by any mechanical cause, as severe inflam- 
mation, pressure from tumors in the neck of the uterus, or from 
excessive use of caustics. It may arise from flexion or version 
of the uterus. It may spring from an intra-uterine polypus acting 
as a ball valve at the internal os, or from a stricture of the vagina,, 
or from an imperforate hymen. 

In this variety the commonest characteristic symptom is the 
paroxysmal pain accompanied by a gush of blood from the genital 
passage. However, the pain is by no means always paroxysmal. 

4. Ovarian. — In this class of cases a careful examination will 
almost always discover some enlargement or tenderness of the ova- 
ries, and reveal a condition which is called chronic ovaritis. As 
chronic ovaritis is never wholly free from some pelvic peritonitis, it 
is easy to understand how the congestion of the menstrual epoch will 
produce a great amount of pain both before and during the flow. 
By careful examination through the conjoined manipulation, one 
or both ovaries can be detected prolapsed somewhat, and perhaps 
nearer to the uterus than is normal. They are characterized by 
their increase in size and by their excessive tenderness. The inac- 
cessibility of these organs to treatment indicates the extremely grave 
prognosis for such patients. 

5. Membranous. — Patients of this class shed, with the flow, a 
membrane which is the decidua wenstrualis. This membrane, 
when whole, consists of a sac representing the cast of the triangular 



MENSTRUATION AND ITS ANOMALIES, 



113 



cavity of the body of the uterus with its three openings, of the Fal- 
lopian tubes and the os uteri. It may come away whole or in 
the shape of shreds and fibres. Microscopically, it is found to be 
what might be denominated hypertrophied decidua menstrualis. 
Tlie blood-vessels are easily seen increased in size, capacity, and 



Fig. 88. 




Membranes of Membranous Dysmenorrhea. 1. Membrane viewed under water ; 2. Small piece of 

membrane ; 3. Smooth cast of \iterus. 



number ; the interglandular substance is greatly increased ; there 
is a great development in the utricular glands, whose mouths are 
visible even to the naked eye. Pregnancy is excluded by the 
entire absence of the chorionic villi. 

The pathology of the dysmenorrheal membrane has received a 
vast amount of attention. Many varying theories have been ad- 
vanced, maintained, and abandoned. The one that is, perhaps, the 
most favored to-day, is that it is an exaggeration of a physiological 
process with a varying pathogeny. In other words, the membrane 
is regarded as an exaggerated decidua menstrualis of inflammatory 
origin. It would seem that the therapeutic proof of this theory 
affords the most convincing argument. Whatever cures the accom- 
panying endometritis in cases of membranous dysmenorrhea is cer- 
tainly, to-day, its most reliable and satisfactory treatment. 

Symptoms. — Pain is the one symptom characterizing every 
variety of dysmenorrhea. A few of its variations are so greatly 
pathognomonic that observation of them is sufficient for a correct 
diagnosis. 

In the neuralgic variety the undulatory character of the pain is 
always pathognomonic. In addition to this characteristic of the 



114 AJSr AMERICAN TEXT-BOOK OF GYNECOLOGY. 

pain, a marked degree of hyperesthesia of the cutaneous surface 
of the lower abdomen will always be found present. The coexist- 
ence of neuralgia in other localities and the identification of Valleix's 
painful points will facilitate the diagnosis. The pain in this variety 
shows itself before the flow has been established, and disappears as 
soon as it comes on, or continues through to the end of the flow, 
coming and going with no apparent cause. It is in this form of 
dysmenorrhea that we find the largest number of incoercible cases. 
The pain may become so agonizing as to make the patient delirious ; 
its severity before, during, and after the flow may be so demoraliz- 
ing to the physical strength of the patient as to ruin her health 
entirely. More cases of destruction of the general health occur in 
this variety than in all the others combined. 

The symptoms of the congestive variety are observed chiefly in 
patients who have previously menstruated painlessly. The pain, 
coming on suddenly, is very severe in this class of cases, seems to 
be confined to the pelvis, and is accompanied by a diminution or 
cessation of the discharge. The constitutional symptoms are always 
marked : the pulse is increased in frequency, the temperature ele- 
vated, the skin hot and dry, and the eyes suffused. There is severe 
headache, occasional delirium, marked diminution in the renal secre- 
tions, and general restlessness. In this variety of the complaint the 
patient usually experiences pain upon walking, is easily fatigued, has 
leucorrhea and an irritable bladder, not only at the time of the flow, 
but during the intermenstrual periods. There is a marked contrast 
in this class of patients to the women suffering from neuralgic dys- 
menorrhea. The pelvic malady seems never to leave them between 
menstruations, whereas women who suffer from a purely neuralgic 
dysmenorrhea experience trouble chiefly at the time of menstrua- 
tion. The syndroma of this form of the disease can readily be 
perceived by bearing in mind the fact that the uterus possesses a 
pathological congestion, not only between the menstruations, but 
throughout all the menstrual flow. 

The symptoms of the mechanical or obstructive form of dysmen- 
orrhea are peculiar and very characteristic. What has been styled 
uterine colic is the kind of pain most frequently encountered. After 
the menstruation has continued for several hours, and some blood 
has accumulated in the fundus uteri sufiiciently to distend it, uterine 
contractions are set up which increase in intensity, until the accu- 
mulated blood is forced out of the uterus in a gush. Then the 



MENSTRUATION AND ITS ANOMALIES, 115 

severe pain ceases for a time until the distention from re-accumula- 
tion occurs, which is followed by another series of uterine contrac- 
tions, terminating in the expulsion of the blood. The obstruction 
to the outflow of the blood may exist in the cervical canal, in the 
vagina, or the vulva. When the obstruction exists in the cervical 
canal, the uterine contractions will expel a small clot of blood, fol- 
lowed by a gush, affording complete relief from suffering for the 
time being. The symptoms are so marked that the diagnosis of 
this form can be made without anv hesitancv, as a rule. The 
physician must be on his guard, however, not to be deceived by 
the accumulation of the menstrual fluid in the vagina, and its 
periodic expulsion in gushes, according as the patient assumes 
various positions, or the cul-de-sac becomes filled. 

The symptoms of ovarian dysmenorrhea are characterized by a 
period of prodromic suffering extending over several days. The pain 
is dull in character, confined to one side when originating from one 
ovar}^ only, extends around the pelvis, over the nates, and down the 
thighs, and is peculiarly liable to be accompanied by an invasion 
of th€ general nervous system and depression of spirits. Painful 
and tender mammary symptoms often occur in this variety. Inter- 
menstrual dysmenorrhea is observed more frequently perhaps in 
this than in any other form of the complaint. Sometimes it occurs 
on the ninth, sometimes on the fifteenth, sometimes on the twelfth, 
and sometimes on the seventh, day after cessation of the menstru- 
ation. Occasionally it is seen only after every second menstruation. 
A pelvic examination often reveals an enlarged, tender, and pro- 
lapsed condition of one or both ovaries. It must not, however, be 
supposed that in all cases of enlarged and tender or prolapsed ova- 
ries, ovarian dysmenorrhea will be found. Not every case of ovarian 
dysmenorrhea presents a detectable pathological condition of the 
ovaries. 

Membraneous Dysmenokehea. — In this variety the pains usu- 
ally begin with the flow. After being ushered in they increase as the 
flow progresses, until the type of veritable labor-pains is reached. 
During the repetitions of these contractions the os uteri dilates, and 
the membrane is shed in its entirety or in shreds from the vaginal 
orifice. Usually the pain ceases at this time ; then ensues a mode- 
rate menorrhagia, which soon disappears. This .is followed by a 
purulent or sero-purulent discharge, continuing indefinitely from 
a few days up to the ensuing menstruation. Sterility is the rule in 



116 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

this class of patients, and the women are of an extremely neurotic 
tendency. The one characteristic of membranous dysmenorrhea 
is the membrane. 

Diagnosis. — The diagnosis of neuralgic dysmenorrhea involves 
the consideration of the entire nervous system. The neuralgic tem- 
perament or diathesis is unmistakably present. Valleix's tender 
23oints are easily determined. The undulating characteristic of the 
pain is always present. The pain is not like labor-pains, as in 
membranous dysmenorrhea, and the suffering is not continuous, as 
it is in the congestive variety. There are no constitutional dis- 
turbances between the menstruations ; there are no signs of endo- 
metritis, of ovarian or perimetritic disturbances. The pain is 
habitual, and not paroxysmal. Between the menstruations there 
are no pains, no leucorrhea, and the patient appears to be in her 
ordinary good health. In the severer forms invasion of the gen- 
eral health often occurs, presenting, in degrees of varying intensity, 
neurasthenia, hysteria gravior, delirium, mania, or epilepsy. 

In the congestive variety, without a conspicuous endometritis or 
general metritis, the attack of pain is sudden. There is an absence 
of constitutional disturbances, and the pain ceases after the flow 
stops. In the congestive variety loith a marked uterine inflamma- 
tion there is always constitutional disturbance, such as rise of pulse 
and increase of temperature, and the patient is never wholly free 
from pelvic suffering between the menstruations. This characteris- 
tic is in marked contrast to the dysmenorrhea from neuralgic origin. 

The diagnosis of the mechanical or obstructive form of dysmen- 
orrhea is made chiefly from the expulsive and paroxysmal occur- 
rence of the pains. A physical examination is necessary to complete 
the diagnosis and to discover what is the underlying pelvic condi- 
tion present. Conjoined manipulation will easily disclose the pres- 
ence of anteflexion. Tumors in the cervix may easily be discovered 
by the finger. Deflections of the uterine canal can be demonstrated 
by the use of the sound. Should the obstruction exist in the vagina, 
it will soon become apparent upon a digital examination. Occa- 
sionally it will be found that the only obstruction existing in the 
uterine canal is an unusual reduplication of the lining membrane 
of the uterus at the internal os, and a spasmodic constriction of the 
muscular fibres at the opening. 

Prognosis. — Dysmenorrhea has usually a favorable j^rognosis. 
In the vast majority of cases of the neuralgic variety the prognosis 



MENSTRUATION AND ITS ANOMALIES. 117 

is entirely favorable. Occasionally it will be found that an inco- 
ercible case of neuralgic dysmenorrhea will be encountered, wherein 
all medical treatment will prove utterly unavailing. In such cases 
there seems, unfortunately, to be but one cure, and that is to induce 
artificially the change of life by the removal of the ovaries. 
Where there is one case demanding resort to this operation, there 
are many thousands that need nothing of the kind. 

Of the congestive variety, the prognosis is almost always favor- 
able, the cure of the patient depending upon the success of the 
treatment instituted for the inflammatory condition present. 

The prognosis of cases of mechanical and obstructive dysmen- 
orrhea depends wholly upon the success of the treatment insti- 
tuted to abolish the obstruction. 

In ovarian dysmenorrhea w^here organic degeneration of the 
ovaries exists, the prognosis is favorable only in case of removal 
of these organs. Where such degeneration is absent, the treatment 
of ovarian congestion or of ovaritis, when successful, will cure the 
dysmenorrhea. 

Membranous dysmenorrhea presents a favorable prognosis in 
the greatest number of cases. Occasionally patients will be seen 
whose general health is so degenerated that all treatment of this 
form of the malady proves utterly fruitless. 

Treatment. — The variety of the dysmenorrhea always decides 
the treatment. No case is intelligently treated wherein an attempt 
at satisfactory diagnosis is not made. In general, it may be said 
that the routine treatment of any form of dysmenorrhea by means 
of the preparations of opium and diffusible stimuli, is to be con- 
demned. There is no question that opiophagists and drunkards 
have been made by this line of inconsiderate treatment. This 
assertion may be disputed, and is disputed, by some physicians, 
but their observations must be considered too limited to be relia- 
ble. This general statement may be made concerning the use of 
these two remedies in dysmenorrhea: He who is compelled to 
resort frequently to opium and stimulants, must be considered 
devoid in diagnostic ability, and consequently ought not to be 
entrusted with the management of such cases. 

Neuralgic Variety. — The treatment of this form may be subdi- 
vided into general and specific treatment. In the beginning of the 
treatment the physician must carefully ascertain the general state 
of the patient. If she be of the rheumatic, gouty, or syphilitic 



118 ^iV" AMERICAN TEXT-BOOK OF GYNECOLOGY, 

diathesis, this must be met by the usual remedies ; in other words, 
the physician must treat assiduously the systemic condition which 
seems to predispose to the development of this neuralgia. The daily 
free administration of laxatives and diuretics is advisable. Should 
a local cause for the constipation be found in the anus or rectum, 
it should be removed by surgery or otherwise. Free daily evacua- 
tions of the bowels are indispensable to the restoration of the 
physiological balance of these patients. Constipation may lead to 
fecal anemia. In women thus affected neuralgic dysmenorrhea is 
extremely common. Rheumatism should be treated with colchi- 
cum, guaiac, the salicylates, and the preparations of potash. Gout 
requires the administration of minute doses of calomel, as one- 
twentieth of a grain three times a day, and wath the citrate of 
potash or lithia. 

Syphilis calls for mercury and iodides. An anemia demands 
tonics. An underlying fermentative dyspepsia, which may be one 
source of degenerated general health, requires gastric lavations, 
creasote, glycozone, and other antiseptic remedies. When the first 
consideration of the treatment of the patient — namely, constitutional 
treatment — has been provided for, then attention should be turned 
to remedies specially addressed to the relief of the suffering. In 
this class of patients purely antineuralgic remedies oftentimes yield 
most brilliant results. Phenacetin and antipyrine will relieve a 
large number of these cases. Many remedies have been recom- 
mended to be given a week before the flow comes on, to prevent 
the pain arising in neuralgic dysmenorrhea. Apiol has been given 
as a preventive of these pains, five minims in a capsule three times 
a day for one week before the flow appears. Five drops of the tinc- 
ture of Pulsatilla, in water, three times a day, is similarly recom- 
mended. If given for a week beforehand, guaiac or the sodium 
salicylate will oftentimes prevent an attack of neuralgic dysmenor- 
rhea in women of the rheumatic diathesis. For the treatment of 
the pain, when it has occurred, auxiliary measures should not be 
neglected, such as rest and the application of warmth to the skin. 
The best results are perhaps yielded by ten or twenty grains of anti- 
pyrine or phenacetin, repeated hourly, until two or three doses, if 
necessary, are given. The best effect from these remedies is 
obtained when the patient lies with closed eyes in a quiet, darkened 
room for half an hour after taking them. Usually one dose of 
phenacetin is sufiicient ; sometimes a second or third dose is neces- 



MENSTRUATION AND ITS ANOMALIES. 119 

sary. The well-known depressant cardiac action of the remedy 
can best be anticipated, if necessary, by the administration of twenty 
or thirty drops of the tincture of digitalis. This remedy, digitalis, 
is occasionally necessary. Nitro-glycerin and amyl nitrate, given 
until flushing arises, oftentimes produce excellent results. Six- 
grain doses of the oxalate of cerium every hour have been recom- 
mended. The tincture of cannabis indica, in twenty-five drop 
doses every three hours, given even to the production of halluci- 
nations, is oftentimes effective. Chloral hydrate in ten-grain doses, 
repeated hourly until three or four doses have been given, will 
often relieve pain. Where the spasmodic element appears to exist, 
as will be indicated by a great diminution of the flow, the solanacese 
will be extremely useful. Thus belladonna, hyoscyamus, or stra- 
monium given to the production of mydriasis is often very effective. 

A general hot bath, from twenty to thirty minutes, frequently 
produces great relief. 

Occasionally the paroxysms of pain are so terrible that we are 
justified in using hypodermic injections of morphine and atropia, 
but they should always be the last resort. 

The treatment of the patient, in cases so severe, should be most 
assiduous and careful, to ascertain if it be not possible to avoid the 
further use of opium. Very rarely a case of incoercible dysmen- 
orrhea, mentioned above, will resist the treatment — even that of 
hypodermic injections — when the removal of the ovaries for the 
artificial induction of the menopause will be imperatively demanded. 

The Congestive Variety. — Herein the treatment must be directed 
by the diagnosis of the cause of the congestion. If it be due to the 
plethora of a retro-displacement of the uterus, the organ must be 
properly sustained. A wool tampon soaked in glycerin, adjusted 
with the patient in the genu-pectoral position, will suffice to thrust 
the fundus forward into its proper place, where the organ can empty 
itself satisfactorily. If upon examination the uterus is found to be 
decidedly congested, as shown by the distended condition of the 
blood-vessels or by the purple appearance of the cervix, leeches 
or scarification will sufiice to relieve. Should the attack be precipi- 
tated by catching cold, the use of the saline cathartics, a diuretic, 
and a diaphoretic will be indicated. When the congestion arises 
from the pressure of an extraneous growth, either within or with- 
out the uterus, the case will be cured only upon the removal of 
the cause. ^ 



120 AN A3£EBICAN TEXT-BOOK OF GYNECOLOGY. 

Mechanical or Obstructive. — The best-recognized treatment of 
ordinary cases of cervical constriction, whether acquired or con- 
genital, is forcible dilatation. If this be decided upon, the patient 
should be thoroughly anesthetized, placed in the lithotomy posi- 
tion, the cervix exposed by the use of retractors, seized with 
the vulsellum forceps and drawn down toward the vaginal orifice. 
The direction of the uterine canal should be determined by the use 
of the uterine sound. If the cervical orifice be too small to admit 
the blades of the Goodell dilator, a narrow dressing forceps can 
first be passed within the internal os, and its blades sufiiciently sep- 
arated to enable the Goodell dilator to be subsequently introduced. 
With the set-screw this dilator can be opened to the extent of an 
inch or an inch and a half, five or ten minutes being consumed in 
its accomplishment. If any evidences of endometritis exist, the 
endometrium should be mildly curetted. Should granulations be 
brought out, then the curetting must be very thorough and the 
entire endometrium gone over systematically. It is not necessary 
to wash out the uterine cavity with an antiseptic liquid, because 
it can be thoroughly emptied with the curette. The irrigation can, 
however, do no harm, and should be practised. A narrow piece 
of iodoform gauze should then be packed into the uterine cavity 
until it is filled, and allowed to remain for a space of two days. 
Subsequent pain of uterine contractions can be held in check by 
the use of moderate doses of opium in some form. This method 
of relieving mechanical dysmenorrhea is remarkably successful in 
the majority of cases, but not in all. Direct electrolytic treat- 
ment of the cervical canal, in a manner similar to that used in the 
treatment of the male urethra, has been urged as an absolutely cer- 
tain one, in j)reference to the dilatation measures. 

Sponge, laminaria, and tupelo tents have been used a great deal 
in the past. Progressive gynecologists rarely resort to their use at 
present, because of the possibility of sepsis following. Forcible 
dilatation has been found much preferable. 

When the constriction does not exist within the cervical canal, it 
is usually the result of some severe inflammation, as from the use of 
caustics or from some cervical laceration occurring in labor. In 
such cases it is necessary to lay open the internal os by cutting 
with a knife or scissors. In order to keep the os patulous the use 
of the intra-cervical stem pessary for two or three months generally 
suffices. When the constriction arises from flexion, the favorite 



MENSTRUATION AND ITS ANOMALIES. 121 

method of treatment is the use of an intra-uterine stem pessary, 
constantly worn for a year or longer. In married women the use 
of this stem pessary is often followed by conception. If the gesta- 
tion go on to term and end in a normal labor, the involution 
of the uterus is usually followed by a return of the flexion. In 
this manner it is shown that uterine flexions are oftentimes in real- 
ity incurable. To meet this condition the operation for the forma- 
tion of an artificial os uteri upon the convex side of the cervix has 
been devised. It consists of the division of the cervix up to the 
point of the flexion and the turning in of the mucous membrane 
to form an artificial os uteri. This surgical procedure is of such 
recent introduction that the verdict concerning its merits is still 
held %ub judice. 

When the obstruction arises from an intra-uterine polypus, its 
removal constitutes the only relief. 

Obstruction residing in the vagina must be treated by dilatation 
either by large bougies, tents, or incision. 

Should the obstruction arise from syphilis, constitutional treat- 
ment must be conjoined. 

Where the obstruction is prc^duced by an imperforate hymen, 
the only relief consists in its division. 

If a fibroid tumor constitutes the cause of obstruction, one of 
the methods for disposing of this condition must be employed. 

The Ovarian Variety. — The treatment of this class of cases is 
perhaps the least satisfactory of all classes of dysmenorrhea. Should 
pregnancy occur, the nine months of rest secured to the ovaries may 
become of signal service. However, in such cases sterility is the 
rule. It is especially in this class of cases that opium and alcohol 
should be avoided. Kemedies to soothe the local irritation and to 
decongest the pelvic organs are to be resorted to. The use of the 
wool-glycerin tampon accomplishes this object the most eflectually 
of all known means. During the flow complete rest in bed and 
low diet, and the free use of bromides for a few days before the 
flow begins, will make many of these patients quite comfortable. 
Hyoscyamus, cannabis indica, exalgine, and stramonium often- 
times give satisfactory results. Internal medication in this vari- 
ety of cases is more often unsatisfactory than otherwise. 

Where unmistakable evidences of organic ovarian disease exist, 
the operation for the removal of the ovaries is demanded. Even 
the removal of the ovaries will at times fail to give the expected 



122 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

relief. Whatever is done to relieve the pain of this variety, short 
of oophorectomy, must, as a rule, be repeated monthly. 

Membranous Variety. — The uncertainty of the pathology of this 
disorder has led to the most astonishing variety of treatments. 
Indeed, it can be said that the same uncertainty of treatment exists 
to-day that existed a quarter of a century ago. The largest num- 
ber of successful treatments of cases has followed the repeated dilat- 
ing and curetting of the uterus. Many times these treatments fail ; 
many more times they are successful. Internal treatment for its 
cure is wellnigh abandoned. A few years ago large doses of iodide 
of potassium were used ; this is now abandoned. All varieties of 
constitutional treatment have been tried and abandoned. The 
consensus of opinion is now centred chiefly upon the treatment 
by dilatation and curettement, in conjunction with the applica- 
tion of chloride of zinc or carbolic acid, for the purpose of destroy- 
ing the portion of membrane left behind by the curette. 



STERILITY. 



Synonyms. — Barrenness ; Infertility ; Lat., Sterilitas matrimonii ; 
Fr., Sterilite ; Ger., Unfruchtbarkeit. 

Sterility in the female implies an inability to bring forth a liv- 
ing child. It involves two points for consideration : first, her 
inability to conceive at all ; and, second, her inability to complete 
successfully the period of gestation. Many women never conceive 
at all. Many other women conceive, but are unable to complete 
the period of gestation. 

Women, who never conceive are said to be absolutely sterile. 
Women who have borne one or two children and do not conceive 
thereafter are said to be relatively sterile. While a woman is nurs- 
ing her new-born child, as a rule, menstruation does not appear. 
During this period sterility generally exists, although women occa- 
sionally conceive even under these circumstances. This condition 
may be called physiological sterility. Under this heading is in- 
cluded that form of sterility which exists and is permanent after 
the woman has passed the change of life. 

Etiology. — Several organs are involved in the process of genesis 
in the female. The essential element of this process is the ovum, 
which is supplied by the ovary. The ovum is conveyed from the 
ovary through the Fallopian tube to the uterus, where it meets the 
spermatozoon, and genesis follows, provided it has not been impreg- 
nated at some point between the ovary and the uterus. The semen 
reaches the uterus through the vagina. Consequently, the question 
of sterility involves the investigation of the condition of, first, the 
ovaries ; second, the oviducts ; third, the uterus ; and, fourth, the 
vagina. In addition, upon the general condition of the patient 
alone non-conception often depends. Under this head may be 
classed the extreme gouty vice, the syphilitic taint, anemia, great 
obesity, chronic alcoholism, and spasmodic dysmenorrhea. 

The Ovaries. — 1. The investigation of the ovaries in sterility 
includes inquiry into the possibility of the absence, or of the im- 

123 



124 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

perfect development, of these organs — conditions rarely met with 
excepting when the other sexual organs are anomalous. 

2. Inflammation of the ovaries, chronic or acute, may result in 
such adhesions of the organs that the ovum is totally prevented 
from entering the oviducts. It may lead to arrest of function, so 
that the ovum can no longer be matured. The ovary may become 
so imbedded in inflammatory deposit that extrusion of the ovum 
from its capsule is no longer possible. 

3. Structural degenerations of the ovary may exist — e, g, cystic, 
carcinomatous, sarcomatous, and interstitial changes — and are gene- 
rally attended with sterility. 

4. Displacement of the ovary, often attended with chronic inflam- 
mation, may place it beyond the reach of the fimbriated extremity 
of the Fallopian tube so completely that the ovum cannot be trans- 
mitted to the uterus. 

The Fallopian Tubes. — 1. Absence or defective development 
of the oviducts is usually associated with other abnormalities of 
the sexual system, and causes hopeless sterility. 

2. Inflammation of the oviducts is a cause of sterility. It may 
affect the serous coat, resulting in such fixation of the tubes as to 
prevent the morsus diaboli from coming in contact with the ovary, 
or in the formation of constricting bands that occlude the calibre 
of the tube. It may attack the mucous lining of the canal, and 
result in the production of secretions which are destructive to the 
spermatozoa or the ova, or it may result in permanent occlusion of 
the opening of the tube, whence may follow collections of blood, 
pus, or serum. In either case the ovum is prevented from de- 
scending to the uterus, and sterility follows. Of most importance 
is the destruction of the epithelia lining the mucous layer of the 
tube, with their cilia, resulting in the inability of the ovum to pass 
along the oviduct, either before it has met the spermatozoon or 
afterward, in the former case the result being sterility ; in the 
latter, ectopic gestation. 

3. Degeneration of the tubal structures produces a hopeless 
occlusion of the canal, and thus causes sterility. 

The Uterus. — Defective development of the uterus assumes vari- 
ous forms, such as its total absence, its under-size, or its abnormal 
lateral growth into either a unicornus or a bicornus uterus. Conoi- 
dal cervix, with the commonly attendant stenosis of the os, may be 
classed as one of the variations of defective development. The last- 



STERILITY. 125 

mentioned condition constitutes one of the most frequently remov- 
able causes of sterility. 

Degenerations. — 1. Myomata often cause infecundity, but they are 
not always a barrier to conception. The coexistence of this degen- 
eration and of pregnancy constitutes one of the most serious con- 
ditions encountered by the obstetrician. 

2. Sarcomata seem always to prevent pregnancy. 

3. Carcinomata, if extensive enough, cause sterility. In their 
early stage conception is often possible, and is now and then 
encountered. 

Abnormalities of Involution. — An excessive involution (hypei'- 
in volution) or a deficient involution (subinvolution) often consti- 
tutes a barrier to conception. The writer recently saw a healthy 
patient, aged twenty-seven, who bore a child at twenty-one years 
of age, and had not menstruated since that event. The uterus 
measured but one and one-fourth inches in depth. The organ may 
be still further decreased in size, even to a quarter of an inch. 

Subinvolution of the uterus is often accompanied with an inflam- 
matory state, completely preventing the occurrence of pregnancy. 

Inflammation of the uterus or the circumjacent tissues is a very 
common cause of sterility. The morbid process, according to its 
seat, may be endocervicitis, endometritis, metritis, or pelvic inflam- 
mation. Often two or more of these conditions coexist and render 
the cure very tedious or impossible. Endometritis may be accompa- 
nied by abnormal secretions destructive to the spermatozoa ; there 
may be a dilated uterine cavity ; the lining membrane of the uterus 
may be made so unhealthy that it becomes impossible for a fertil- 
ized ovum to secure a lodgment thereon ; or the inflammation may 
cause more or less occlusion of the uterine orifice. 

Displacements. — Malpositions of the uterus include 23rolapse, 
flexions (retroflexion, anteflexion), and versions (anteversion, 
retroversion, and lateroversion). 

Anteversion and anteflexion exist most frequently in nulliparae. 
Retroversion and retroflexion exist most frequently in those who 
have borne children. Lateral displacements are present when 
an inflammation has existed in either broad ligament, resulting in 
its shortening, or when some foreign growth or an inflammatory 
deposit exists on the side of the pelvis, opposite to the displace- 
ment, crowding the uterus away from its normal position. 

The Vagina. — This organ may be so injured, or may become the 



126 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

seat of discharges so fatal to the semen, that it becomes a source of 
sterility. 

Malformations. — The vagina may be absent congenitally. Its 
occlusion is very rare, but exists, both as a congenital and an acquired 
condition. A severe vaginitis has been the cause of an almost total 
occlusion, by the agglutination of the vaginal walls. The hymen is 
sometimes so hypertrophied that it becomes a barrier to copulation. 
Unnatural shortness of the vagina renders it incapable of retaining 
the semen for a suitable length of time. 

Inflammation. — Vaginitis nearly always produces discharges fatal 
to the semen. It is occasionally productive of that condition of 
spasm called vaginismus, but this is more frequently caused by 
other conditions. 

Injuries. — Extensive jjerineal lacerations often become causes 
of sterility by shortening and straightening the vagina. Fistulse 
may also prevent conception. 

Degenerations. — Elephantiasis labiorum prevents coitus, and 
thus becomes a barrier to insemination. Extensive urethral carun- 
cle often interferes with successful intercourse. 

General State of the Patient's Health. — An indefinable 
something in the patient's general condition is oftentimes the appar- 
ent cause of sterility. The proof of this statement consists in the fact 
that women sterile when in poor health often conceive when their 
general condition has been improved by remedies, by change of 
climate, or by travel. Some women are sterile because of the pres- 
ence of discharges from the genital tract which have their origin in 
a systemic taint. The lithemic state, for example, may give rise 
to discharges, which cease when an antilithic course of treatment 
has been followed, and conception thereafter may follow. Many 
cases of sterility of this form have been wholly removed by a 
course of treatment at suitable mineral springs. 

Under this head may also be mentioned that variety of steril- 
ity which is dependent upon some obscure incompatibility of the 
parties, illustrations of which every physician of experience has 
encountered. A woman, sterile in many years of married life, 
who has been for this reason abandoned by her husband, eventu- 
ally secures a divorce, is married to a second husband, and bears 
a number of children. The old illustrations of Augustus and 
Livia and of Napoleon and Josephine are quoted by writers on 
sterility. 



STERILITY. 127 

It is well never to lose sight of the fact that the cause of ster- 
ility may be resident in the male, and when no cause can be found 
resident in the wife, a critical examination of the husband should 
be made. Not infrequently the physician will be rewarded by the 
discovery of the defect. It is possible that, in a certain proportion 
of the cases, when the woman has conceived by a second marriage 
the defect existed in the first husband. 

Diagnosis. — It is not always the case that only one of the foregoing 
obstacles to conception is present. Very often two or more of them 
coexist. When the causes of sterility are manifold in the same 
patient, it is obvious that the skill of the gynecologist will often be 
taxed in recognizing and removing them. A complete diagnosis 
can be arrived at only by an exhaustive examination. It is always 
a safe plan for the physician to endeavor to find all of the possible 
causes of sterility in his patient. 

Frequently, after every discoverable obstacle to conception has 
been corrected, sterility will still exist. 

Prognosis. — In no condition is the prognosis more uncertain. 
In a general way it may be stated that imperfect development or 
marked malformations constitute an absolute bar to conception. 

In the same manner, it may be stated that removable obstacles 
to conception, as inflammations, flexions, versions, stenosis, some 
vaginal occlusion, or fistulse, may be treated with a fair prospect of 
fruitful results. The apparently complete removal of these obsta- 
cles, however, only too often fails to render the woman fruitful. 

Treatment. — A successful treatment of sterility in the female is 
secured by removal of all the obstacles to conception. Such treat- 
ment does not include that of sterility in the male, although many 
gynecologists investigate the male first, since about one case in ten 
of infecundity in marriages has its origin in the male. With this 
branch of the subject, however, the present article has nothing 
to do. 

After the physician has discovered as many obstacles to concep- 
tion as he can find, he must set about removing them. Insufficient 
treatment nearly always results in failure. In no department of 
gynecology is more persistence in treatment demanded. 

Urethral caruncles, vulvar vegetations, and other sensitive ex- 
crescences must be removed or destroyed. 

Vaginal stenosis or contraction must be stretched, and the canal 
kept patulous. 



128 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Cervical stenosis must be overcome by sea-tangle or tupelo tents 
or by stretching with dilators. Division of the cervix by the 
hysterotome has been successfully practiced in the past, but is at 
present falling into disuse, forcible dilatation being preferred. 

Uterine deviations must be corrected. Versions can often be 
rectified by suitable pessaries. It has been suggested that ante- 
version may be corrected by allowing the bladder to become dis- 
tended with urine, thus pushing the fundus uteri backward and 
throwing the cervix sufficiently forward, to place the os in a direct 
line with the seminal ejection ; the entrance of the semen into the 
cervical canal is thus facilitated. Similarly, retroversion, it is 
alleged, may be temporarily corrected by allowing the rectum to 
become distended with feces, whereby the fundus uteri may be 
crowded forward. It would seem most probable that both these 
procedures would defeat the desired object. Either one or the other 
would tend to destroy the natural S-shape of the vagina, producing, 
in a milder degree, the same condition of straightening of the canal 
as is produced by laceration of the pelvic floor. Especially in the 
case of constipation the result would be a tendency to non-retention 
of the semen in the vagina. The theory of sterility being due to 
a backward or downward position of the cervix has long been ex- 
ploded. 

Flexions demand the use of the intra-uterine stem pessary. 

Hyperin volution may be treated with the galvanic intra-uterine 
stem pessary. Similarly, attempts may be made to stimulate the 
growth of an imperfectly developed uterus. 

Inflammations must be treated secundum artem. Various anti- 
phlogistic methods of treatment are in vogue. Cauterizing applica- 
tions, hot-water douches, glycerin tampons, the dry treatment of 
Englemann, etc., each has its adherents. 

Morbid growths on the endometrium must be removed or de- 
stroyed. 

Quite exceptionally, the method of introducing semen into the 
uterus by means of a syringe and tube has been used, it is alleged, 
successfully. 

In the treatment of all cases of sterility the physician must never 
ignore the general condition of the patient. Systemic vices must 
be eradicated as far as possible. Many cases of sterility can be 
cured by general treatment. Repeated abortions indicate the pos- 
sibility of the syphilitic taint. The existence of this vice in a 



STERILITY, 

Fig. 89. 



129 




Apparatus for Artificial Impregnation. 



marked degree is an almost certain obstacle to the chances of gesta- 
tion being completed, and it must therefore receive continuous and 
persistent treatment for a period of at least two years. 



ANOMALIES OF THE FEMALE GENERATIVE ORGANS. 



By anomalies of the female generative organs we mean the con- 
genital (not acquired) partial or total absence, the arrest of, or 
excessive development, or a peculiar formation or malposition of 



Fig. 90. 








Development of the External Genital Organs— diagrammatic. 1. P, rectum, continuous with All, allantois 
(bladder), and M, Miiller's canal (vagina) ; x, depression of the integument below the median tubercle, 
which by its progress inward forms the vulva. 2. The depression has extended inward to become 
continuous with the rectum and the allantois to form the cloaca, CI. 3. The cloaca has split into the 
uro-genital sinus, Su, and the anus, u, by the down growth of the perineal septum. The Miillerian 
canals are fused to form the vagina, V, behind the bladder, B, and the orifice of the urethra, u. 4. 
The perineum completely formed. 5. The upper portion of the uro-genital sinus contracts to form 
the urethra ; the lower portion persists and forms the vestibule, su, into which both urethra and 
vagina empty. 








Malformation of the External Genital Organs— diagrammatic. 1. Complete atresia of the vulva: r, 
rectum ; g, genital canal ; b, bladder, communicating with both. 2. Complete atresia of the vulva: 
r, rectum, separated from the allantois; &, bladder, and g, genital canal, distended with urine. 3. 
Atresia of vagina and anus: d, perineum, incomplete; 6, bladder; v, vagina, and r, rectum, open 
by a common cloaca. 4. Hypospadias in the female : first degree coincident with hypertrophy of the 
clitoris ; s, persistent uro-genital sinus, to which succeeds the long vestibular canal ; u, urethra, and v, 
vagina, opening into the vestibular canal; c, hypertrophied clitoris. 5. Hypospadias in the female, 
properly so-called ; the allantois wholly transformed into a bladder, which opens directly, without the 
intermediate urethra, into the uro-genital sinus— that is, into the vestibule. 

130 



ANOMALIES OF THE FEMALE GENEBATIVE ORGANS. 131 

any part of the generative tract, considered first, in general, as 
abnormalities of the external and internal zones; and, secondly, as 
abnormalities in individual organs, dividing them for consideration 
into : 

1. General anomalies of the two zones : true and apparent her- 

maphrodism. 

2. Anomalies of the separate organs : 

a. The external zone : the vulva, labia, nymphae, clitoris, 

and the vagina; hypospadias and epispadias. 

b. The internal zone : the uterus, Fallopian tubes, and 

ovaries. 

I. General — Total Absence of Either or of Both Zones. 

There is on record no authentic case of entire absence of both 
external and internal generative organs in the same person. Occa- 
sionally there have been reported cases of acephalic fetuses, prema- 
turely born, in which no trace of generative organs could be dis- 
covered, but these are extremely rare ; more than that, no authentic 
cases have been proven, although many have been described, in 
which the external genitals have been entirely lacking ; in every 
case properly examined rudimentary processes have been found. 

Foville reported a case in which there was absence of the nym- 
phae, labia, and clitoris, with a fusion of the vestibule ; a minute 
opening only was present, the outlet of the urogenital canals, 
through which the urine and menstrual fluid passed. In this 
case Klebs claimed there was fusion of the raphe. Meckel has 
described some old cases of entire absence of the genitals, but in 
these cases there was a depression or an elevation where the vulva 
should have been, and the details of the examinations were so 
meagre that they cannot be called authentic cases. The complete 
absence of the internal organs of generation is an extremely rare 
anomaly, if it exists. Kussmaul describes a female in which the 
most careful examination showed no signs of uterus, ovaries, or 
tubes, and where the vagina existed as a minute opening. Emmet 
records a case where a woman, so called, had been married for two 
years, but had never menstruated. An examination showed that 
sexual intercourse had been carried on through the urethra and 
into the bladder. In this case he was unable to discover any signs 
of vagina or uterus. 

Other writers have described similar cases, but in few of them 



132 ^iV^ AMERICAN TEXT-BOOK OF GYNECOLOGY, 

has an autopsy been obtained, and then, in each case examined, rudi- 
mentary organs have been discovered. 

True Hermaphrodism, in wJiich one or more of the generative organs 
of the male and female are present in the same individual. 
Dohrn denies the existence of true hermaphrodism in the human 
race, however common it may be in the vegetable and animal king- 
doms, while Skene mentions Hildebrant and Bannon as having 
authentic cases which they reported. Klebs classified hermaphro- 
dism into — 

1. Bilateral, where the ovaries and testicles exist simultaneously 

on both sides ; 

2. Unilateral, where both ovary and testicle are present on one 

side at least ; 

3. Lateral, where the ovary and testicle are present on different 

sides. 

Ahlfeld claims that there has never been on record a proven case 
of unilateral hermaphrodism, and that he has his doubts about the 
existence of bilateral hermaphrodism. Zweifel agrees with him in 
this. Ahlfeld mentions the cases reported by Heppner and Schnell 
of bilateral hermaphrodism, but there was so much difference of 
opinion about them that certainly nothing definite was proven. 
Zweifel quotes the following men as having recorded cases of lateral 
hermaphrodism : Sue, Barkow, Berthold, Bannon, Meyer, Gruber, 
and Klotz. Courty divides true hermaphrodism into lateral, trans- 
verse, and vertical or double, and says : " Two cases are now recorded 
— one by Kokitansky and another by Heppner — which prove to 
a certainty that the simultaneous presence of organs, characteristic 
of both sexes, may be found in the same individual, not only the one 
on one side, the other on the other, but simultaneously on the same 
side." The autopsy in Rokitansky's case in 1869 showed two ova- 
ries with their tubes, a rudimentary uterus, and one testicle, with 
vas deferens containing spermatozoa. This individual menstruated 
regularly, and had an imperforated penis and a bifid scrotum. The 
case of Heppner, the second one he reported, was the autopsy upon a 
six weeks' infant, in which he found a complete internal generative 
apparatus, a penis, hypospadias, and two supernumerary glands, 
which he pronounced to be testicles. Slavjansky declared that 
these two supernumerary glands were ovaries, and not testicles. 

Zweifel says of congenital hermaphrodism : ** In not a single 



PLATE XII. 




\ 




Pseudo-external Bilateral Hermaplirodism. 



ANOMALIES OF THE FEMALE GENERATIVE ORGANS. 133 

case as yet, however, have spermatozoa been found in hermaphro- 
dites, the ejaculations consisting simply of such a fluid as even 

Fig. 92. 




Pseudo-hermaphrodism proper. External genitals of Julia D (man). Feminine appearance of the 

parts with the penis raised and the thighs separated : b, frsenum ; mu, meatus ; ov, vulvar orifice. 

females secrete on irritation of their sexual organs." Still, it is 
certainly a fact that the tendency in the majority of cases is toward 
the male type, and that nearly all, if not all, authentic cases have 
been of lateral hermaphrodism. In apparent or pseudo-hermaphro- 
dism the female may simulate the male type, by an abnormal devel- 
opment of the clitoris and a hernial descent of the ovary into the 
labia, as described by Auger ; or, in cases of hypospadias the male 
may resemble the female, the fissure of the corpora cavernosa being- 
taken for a vagina, and the penis, which in these cases is nearly 
always atrophied, being mistaken for an hypertrophied clitoris. In 
some of the cases described, the non-descent of the testicles into the 
scrotum made the diagnosis more difficult. Vice versa, Junie, Coste, 
Engel, and Huguier describe cases of hypospadias in the female, 
with hypertrophy of the clitoris, that were regarded and reared 



134 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



as males. Leopold recorded a case in which a male pseudo-her- 
maphrodite was married as a female. There existed, in place of the 
vagina, a cul-de-sac. Oldham cites two cases where herniated ova- 



FiG. 93. 




Pseudo-hermaphrodism proper. External organs of Louise B (man) : g, glans ; h, frsenum ; ov, vul- 
var orifice ; hy, hymen ; /, fourchette ; pi, nymphse ; gl, labia majora. 

ries in persons who had never menstruated gave rise to a mistake 
of sex. Ricco and Steglehuer reported cases of the same sort. 

II. Anomalies of the Separate Okgans — the External 

Zone, Vulva, Labia, etc. 

Louis and Petit mention cases of acephalic monsters in which 
there was complete absence of the vulva. Two cases were described 
by Riolan in which the left labium majus was lacking. Kussmaul 
describes Rossi's case, where the vagina existed as a most minute 
opening, and Foville's case, referred to before, showed an absence 
of labia, nymphse, and clitoris. Coste and Beggel have on record 
cases where the labia were undeveloped, being represented by lit- 
tle ridges of integument. 



ANOMALIES OF THE FEMALE GENERATIVE ORGANS. 135 

Meckel, Granville, and Mayer have cited instances where the 
labia majora have been rudimentary or lacking. There are, of 
course, many cases on record of a lack of development of the 
external genitals as a whole, and where the parts, even in adult 
life, resemble those of an infant. Cases of hyper-enlargement 
or multiplication of the labia are not so rare. Meissner, Morga- 
gni, Winckel, and Neubauer mention cases where there have been 
three and fourfold labia and nymphse. Zweifel quotes Halle as 
recording a case in which the nymphse covered the anus. Among 
certain tribes (the Hottentots, for example) the labia are of enor- 
mous size and hang down for six or eight inches (the Hottentot 
apron). 

Arnaud and Morpain describe cases of absence of the clitoris, 
and Mannosi refers to a case in which an autopsy showed no sign 
of even a rudimentary clitoris. Zweifel mentions Meissner as quot- 
ing unquestionable cases of congenital hypertrophy of the clitoris, 
reported by Tulpius, DeGraaf, Zachias Avicenna, Plater, Rhodius, 
and Panarali. Frick, Armand, and Coste report cases of hypertro- 
phy where the clitoris was as large as an erect penis. Ahlfeld 
describes several cases of this sort in full. The clitoris, like all 
the other generative organs, may remain in an undeveloped state, 
and yet, according to some writers, may not be, properly speaking, 
an anomaly. 

Congenital hypospadias and epispadias are not uncommon in 
the female. In epispadias the clitoris is split at its upper or lower 
portion, as the case may be. Roser, Schroder, Gosselin, and Teste- 
lin have reported cases. Roser's and Schroder's were operated upon 
and cured by Moricke and Frommel. In hypospadias the posterior 
wall of the urethra is lacking, the canal opening upward into the 
vagina. There is seldom a fissure of the clitoris in cases of hypo- 
spadias. 

The Hymen. — Roze, in his interesting thesis, goes fully into the 
question of the abnormalities of the hymen, and Courty, in his work, 
discusses the question in full. Illustrations are given of the dif- 
ferent anomalies. 

Zweifel writes that '' very likely, atresia of the hymen is not 
an anomaly of development," and quotes Briesky as expressing 
the opinion, that it is simply the secondary obliteration of a pre- 
viously formed canal, through defective hornification of the super- 
ficial epithelium. Briesky in his chapter on congenital malforma- 



136 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

tion says : '' Hymenial atresia, however, is excessively rare as an 
acquired condition," and he states that he has but once met 
with a true atresia hymenalis in a new-born girl. The genitals 
were otherwise normal in this child. He gives an interesting list 
of eighteen cases of hymenalis and vaginal atresia operated upon 
and cured by him. Zweifel himself had a case of " atresia hymen- 
alis " where the entire vagina was affected by this epithelial adhe- 
sion ; so, too, the cases reported of double hymens are simply adhe- 
sions of the epithelial cells. 

The Vagina. — Atresia or absence of the vagina may be par- 
tial or total, and, according to Courty, may coexist with absence 
of the uterus or with a normal uterus. Cook, Yagishita, Matters- 
dorf, and Barsony have lately recorded cases of congenital vaginal 
atresia. Atresia of the vagina, to quote Briesky, is probably due to 
a secondary adhesion, as is atresia of the hymen, rather than to 
an anomaly of insufficient formation. Bokal and Zweifel seem 
to agree with him in this theory. Briesky goes on to say that the 
arrest of development may be of two kinds — cloaca, due to defect- 
ive division between the rectum and bladder, and the existence of 
intravaginal septa. The cloaca may be complete or incomplete ; 
the latter may be uro-genital or recto-genital. " The atresia of 
the upper and middle portion of the vagina is due to the loss 
of the existing lumen of the divided or united vaginal portions 
of Miiller's ducts," but when the lower vaginal part is wanting, 
there may be a total absence of the lower part of the Miillerian 
ducts. Courty describes complete uro-recto- vaginal cloaca in a 
new-born child, and a recto-vaginal cloaca in a girl of sixteen, who 
had an imperforate hymen and menstruated through the anus. He 
cites several other cases of cloaca more or less severe. There mav 
be a transverse division of the vagina, the so-called double hymen, 
or a longitudinal division, either from right to left — a rare anomaly 
— or from before backward, the so-called double vagina. These 
divisions may be complete or incomplete. Puech states that more 
than one hundred cases of this anomaly have coexisted with anom- 
alies of the uterus, and less than fifteen have been reported with a 
normal uterus. Great differences exist as to the length and breadth 
and shortness of normal vaginae ; anomalies of excessive length, 
etc., have been described by Toison, Scanzoni, Courty, Zweifel, and 
Puech. 



ANOMALIES OF THE FEMALE GENERATIVE ORGANS. 137 

Inter7ial Organs (the uterus, Fallopian tubes, and ovaries).— 
The Uterus. — The division of uterine anomalies is as follows : 
I. Defectus uteri. Total absence of the uterus. 
II. Rudimentarius uteri. Rudimentary uterus. 

III. Uterus unicornis. The one-horned uterus. 

IV. Uterus bicornis. The two-horned uterus. 
V. Uterus septus. Two-chambered uterus. 

VI. Uterus duplex or didelphys. The double uterus. 
VII. Defectus et rudimentarius cervix uteri. Defective and rudi- 
mentary cervix of the uterus. 
VIII. Abnormalities of position. 
Borner gives as the probable ultimate causes of the faults of 
development in the uterus the following: 

1. Interference with the approximation of union of the two 
lateral organs which go to form the uterus. 

2. Interference with the disappearance of the vaginal septum 
formed by the union of the median walls, which gives the double- 
cavitv uterus. 

3. Nutritive disturbances in the original genital structure. 

4. The fact that the obstacle to development may occur so early 
in fetal life that the foundations of a part of the uterine structure 
are not laid ; in this way a segment on one or both sides may be 
missing. Hart and Barbour give as the two causes which together 
operate to produce malformations, arrested development and arrested 
growth. 

I. Defectus Uteri. — Kussmaul and Borner claim that the uterus 
is rarely if ever entirely wanting, and that an autopsy on any case 
will reveal some vestige of a rudimentary or atrophied organ. 
Courty quotes a case in which there was claimed a total absence 
of the internal organs of generation. Borner, Quain, and Stegle- 
huer report cases in which, on the living subjects, they could find 
no trace of uterus, ovaries, or tubes. In monstrosities in which no 
uterus was found, no traces of the Miillei-ian ducts were discovered. 

II. Uterus Hudimentarius. — Veit, Langenbeck, and Nega have 
described cases where the uterus seemed little more than a thicken- 
ing on the posterior vesical wall. Cases have been reported varying 
from this highest grade of deformity to the approach of the normal. 
The ovaries in these cases are generally present, and are often nor- 
mal ; there is no trace in the more pronounced cases of any periodic 
ovulation. Borner, Tauffer, Langenbeck, and Peaslee report cases 



138 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



where relief was sought for pains and backache occurring regularly 
each month, but without ever being accompanied by menstruation. 



Fig. 94. 




Solid Rudimentary Uterus, consisting of one Cervix and two Horns : a, bladder cut open ; 65, ureters ; cc, 
umbilical arteries ; d, rectum ; e, cervix ; ff, cornua of tbe uterus ; gg, round ligaments ; hh, ovaries 
with follicles ; i, rudiment of the Fallopian tube ; kk, peritoneal duplicature of the ovaries. 

In a case of this sort Leopold operated and removed a rudimentary 
left uterine cornu and ovary with a perfect recovery. 



Fig. 95. 



Fig. 96. 





Uterus Bipartitus : a, closed vagina ; &, cervix uteri ; 
cc, cornua of the uterus ; dd, hollow expansion of 
the cornua ; ee, atrophied ovaries ; /, Fallopian 
tube ; gg, round ligaments ; hh, broad ligaments. 



Infantile Uterus. 



III. Uterus Unicornis. — An anomaly in which only one horn of 
the uterus has been developed, the Miillerian duct on the opposite 
side being atrophied, absent, or undeveloped. In this case the ute- 
rus is elongated and lies, obliquely bent, to one or the other side. 
Pregnancy in these cases occurs naturally, if the vagina be normal, 
and the shape of the uterus causes the fetus to lie vertically. In 
a case of Moldenhauer's, on delivery, rupture of the uterine walls 
occurred. Hegar, Frankenhausen, Borniski, and Borner describe 
cases where one cornu was atrophied. 

Koeberle performed Csesarean section and removed piecemeal a 
fetus from a right uterine horn. 

Salin, Litzmann, and Sanger performed abdominal sections for 



ANOMALIES OF THE FEMALE GENERATIVE ORGANS, 139 

the removal of diagnosed dead fetuses, and found that in each 
case conception in a uterus unicornis had occurred. 

Fig. 97. 




Uterus Unicornis with rudimentary coruu : LH, Lo, LT, and L Lr, horn, ovary, tube, and round ligament 
of the left side ; RH, Ro, RT, and R Lr, those of the right side. 

IV. Uterus bicornis is the result of a non-union of that part of 
the Miillerian ducts which goes to form .the body of the uterus, 
leaving a division or fissure, more or less pronounced, from before 
backward over the fundus, separating the cornu, which projects at a 
more or less obtuse angle, each cornu having its distinct cavity. The 

Fig. 98. 




uterus Bicornis. 



uterus in these cases is often twisted on its long axis, and may contain 
a partition -wall. Cases have been recorded in which the uterus and 
the cervix have been divided into two separate compartments. The 
two horns are seldom equally developed, but the ovaries and tubes 
are generally normal ; the vagina, however, often has the same 
duplexity. There may be atresia of one of the horns. In cases 
of extreme separation of the two halves, menstruation does not 
always occur simultaneously from the two cornu. and in some cases 
a pregnancy in one half does not interfere with menstruation from 
the other. Henderson made interesting notes on a case of this kind, 
watching the woman for sixteen years and delivering her of six 



140 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



children. In two or three of these pregnancies she menstruated 
during the whole term. 

Gouterman reports a case in which pregnancy occurred in each 
horn separately and at different times. 



Fig. 99. 




Bicorn Unicervical Uterus. 

V. Uterus septus is a uterus normal in shape and generally in 




Uterus Septus: aa, tubes; bb, fund as uteri; ccc, septum; dd, the cavities of the two uteri ; ee, intertml 
OS ; ff, external wall of the two cervices ; gg, external orifice ; hh, vaginae. 

size, but internally divided into two cavities by a partition. This 
partition may be complete, extending from the external os to the fun- 



ANOMALIES OF THE FEMALE GENERATIVE ORGANS. 141 



dus, or may be incomplete and only extend part of the way. In this 
anomaly the ducts of Miiller have coalesced, but the partition-wall 
has not been absorbed. Blackwood recorded a case in which men- 
struation occurred alternately from either side. This abnormality 
interferes very little with pregnancy, but if the placenta is attached 
to the thin partition- wall, profuse hemorrhage may occur. Ruge 
recently split the partition-wall in a woman who had miscarried 
twice, and in the third pregnancy she was delivered at term. 

VI. Uterus duplex or Didelphys. — The development of two com- 
plete and independent uteri, with no partition-wall and no adhe- 
sions. Mayrhofer claims that this anomaly can only occur with 

Fig. 101. 




Didelphic Uterus and Divided Vagina: a, right segment; 6, left segment; c, cZ, right ovary and round 
ligament ;/, e, left ovary and round ligament; g,j, left cervix and vagina; fc, vaginal septum; h,i, 
right cervix and vagina. 

changes that would render life impossible, and so thinks that cases 
reported as duplex are only cases of septus. 

In Olliver's interesting case the autopsy showed two distinct 
uteri, separated by folds of the intestines from each other ; and 
Olliver quotes Bonnet as having had the same sort of a case. 
Heitzmann's case was similar to this, with the additional fact that 
not only the bodies of the two uteri, but also the two cervices, were 
widely separated. In all these cases there was but one set of 
appendages to each uterus, and but one broad and lateral ligament. 

Winckel and Cassau have reported similar cases, and Schroder 
one in which the rectum was between the two uteri. Menstruation 
has been in these cases normal. Satschowa reports a case where 
both cavities were gravid at the same time. 



142 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

VII. Abnormalities of the cervix uteri are common both in the 
size and shape of the canal and the external os, and in the size and 
shape of the cervix itself. These are well described by Courty in 
his work on the uterus, ovaries, and tubes. Winckel and Heitz- 
mann have recorded cases of a double os uteri, or a normal uterus 
and cervix with the external os divided into two parts by an unab- 
sorbed partition. Borner describes a case of his own of complica- 
tion of the cervical cavity, which appeared at first sight like a cervix 
within a cervix, and quotes a case of Breisky's at Berne which was 
of the same kind. Borner was the first to describe this anomaly, 
and considers it extremely rare. 

VIII. Abnormality of position is caused probably by the insuf- 
ficient development of one of the Miillerian ducts, although united 
to its opposite duct; again, there may be a difference in the position 
of the two Miiller's ducts, one being lower than the other, so that 
the fundus when developed is bent to the right or left as the case 
may be, or even twisted upon itself. 

Kussmaul found this malposition in an autopsy upon a child, 
and in his case, one of the lateral ligaments was abnormally short. 
Fetal inflammations may play their part in these abnormalities. 
Sterility generally is present in these cases. 

The Abnormalities of the Fallopian lubes. — The entire absence of 
the Fallo23ian tubes rarely occurs, Courty says, even when the uterus 
is entirely absent. In cases of uterus unicornis, both the tube and 
ovary are lacking on the undeveloped side. Winckel, in post- 
mortem examination of 500 female bodies, found the tubes to be of 
unequal length in 25 ; in 3 cases the tubes were from 4 J to 5 inches 
long; and in 2 cases he found accessory tubal ostia. Klob and 
Bokitansky have called attention to the differences in form of the 
ends of the tubes, and described supplementary openings that some- 
times occur at or near the ends. Hen nig described three cases of 
accessory tubes, and Bandl reported a case in which the tube was 
normally developed, but imperforated. Congenital abnormalities 
of position and development of the uterus naturally give rise to 
abnormalities of position of the tubes, and congenital hernias of the 
ovaries carry the tubes with them as a rule. Olshausen says : " In 
some, the Fallopian tube is defective, and its internal extremity is 
alone developed ; its abdominal extremity is destitute of fimbria 
and obliterated." Keppler describes a supernumerary tube with 
a corresponding third ovary, that occurred in one of his cases. 



ANOMALIES OF THE FEMALE GENEBATIVE ORGANS, 143 

Ovarian Anomalies. — Congenital absence of both ovaries, like 
absence of both tubes, probably occurs only in non-viable mon- 
strosities, according to Olshausen, and reported cases in individuals 
cannot be considered authentic, since torsion and constriction may 
cause such marked atrophy as to leave little, if any, vestiges of the 
once-present ovary. Rokitansky demonstrated this condition in 
several of his cases. Absence of one ovary only occurs in cases 
of uterus unicornis. Grohe first reported a case of supernumerary 
ovary, and mentions a second case described by Klebs where the 
constriction of a band cut the ovary into two halves, each contain- 
ing Graafian follicles in a rudimentary state. 

Sinety's autopsy on a new-born babe showed six appendages to 
one of the ovaries : one of these appendages showed normal ovarian 
structure, while the rest were cystic. 

Keppler, as mentioned before, found a third ovary and tube in 
one of his cases. Kochs, Lumniczer, and Winckel describe similar 
cases. Beigel found appendages to normal ovaries containing 
ovarian tissue 8 times in 350 post-mortems, and Winckel 18 times 
in 500 autopsies. Waldeyer found 6 in one ovary. These extra 
ovaries are generally bilateral ; their peculiar feature is their imper- 
fect development. Klebs declares that ovaries, in which germinal 
epithelium projects into the stroma, with separation of these tubes 
from the surface epithelium, without the development of follicles 
and ova, are similar in many ways and in appearance to testicles. 



GENITAL TUBERCULOSIS. 



Genital tuberculosis in the female may exist as a primary 
affection, although in the great majority of cases it is secondary to 
tubercular disease elsewhere. As a primary affection it has been 
found in from 5 to 15 per cent, of cases. J. Whitbridge Wil- 
liams collected statistics showing genital tuberculosis in from 1 to 
8i per cent, of autopsies on phthisical women, and in 1 of every 12 
abdominal sections for inflammatory disease. Cohabitation with 
one affected with tuberculosis of the genital, urinal, or intestinal 
tract may be the cause. Inoculation may occur by means of an 
instrument, finger, clothing, or other foreign body contaminated 
with the germs. It seems possible that the tubercle bacilli may 
enter the blood and obtain their first foothold in the diseased 
genital organs. 

As a secondary affection genital tuberculosis may be caused by 
excursions of the germs from distant parts, through the blood- or 
lymph-channels ; by direct extension, as from the peritoneum, 
intestines, or urinary organs ; or by auto-inoculation through the 
infected urinary, alvine, pulmonary, or other excretions and dis- 
charges. 

Tuberculosis of the Vulva. 

Primary tuberculosis of the vulva is almost necessarily a skin 
affection, and occurs only in the form of lupus, unless we except 
those cases of coincident vaginal and vulval ulceration observed by 
Deschamps, Chiari, and Zweigenbaum. In these cases the disease 
was probably of vaginal origin^ and not a true tuberculosis of the 
vulva. 

Lupus begins on the cutaneous portions of the vulva in the form 
of hard masses, of a dark-red, livid color, imbedded in indurated skin. 
Sometimes there will be one large mass, sometimes a more diffused 
infiltration with several masses. On the dull-red or yellowish- 
brown surface or surfaces, brighter red, projecting tubercles appear, 

144 



GENITAL TUBERCULOSIS, 



145 



which in a few weeks or months commence to ulcerate and exude 
a serous fluid. When there is but a single mass, the whole surface 
assumes the appearance of a raised, unhealthy ulcer, while, in the 
diffuse variety, the ulcers may be separated. The base is hard and 
does not usually bleed easily, and is composed of friable, unhealthy- 

FiG. 102. 




Lupus hypertrophicus et perforans of the Vulva. 

looking granulation-tissue. As the disease spreads it takes in more 
and more of the skin, and finally invades the lymphatic glands and 
internal organs. The course is usually slow, extending over years, 
and in old cases is often accompanied by cicatricial contraction in 
places, thus producing more or less deformity. The general health 
does not, at first, suffer, but the disease, after lasting several years, 
usually ends fatally. 

The DIAGNOSIS presents no real difficulty, for its slow develop- 
ment and chronicity distinguish it from cancer and malignant dis- 
ease, while the ulcerative characteristics differentiate it from ele- 
phantiasis. 

The TREATMENT should always be radical. When possible, the 

10 



146 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



diseased parts should be extirpated. When not, a thorough curetting 
with a sharp instrument, followed by a disinfection of the wound 
with strong acid, may be tried and repeated as often as the disease 
returns. Free incisions or linear scarifications favor cicatrization 
and healing. Deep cauterization by means of electro-puncture is 

Fig. 103. 




Lupus of the Vulva. 

the most satisfactory way of treating many cases, for all parts of the 
diseased tissue can thus be reached and cicatrization secured. The 
treatment must be repeated as fast as the disease recurs or redevel- 
ops, until all foci are finally destroyed. 

Tuberculosis of the Vagina. 

Tuberculosis of the vagina is usually secondary, although a few 
cases have been observed in which no other foci of the disease could 
be discovered. 

It commences in the form of miliary tubercles, which in time 
break down and form irregular, flat ulcers with sharply-defined 
edges and a depressed grayish or yellowish-gray base, studded with 



GENITAL TUBERCULOSIS. 147 

granulations and covered by caseous matter. An area of hyperemia 
more or less filled with miliary tubercles usually surrounds the 
ulcer. 

Tubercular fistula may result either from the vaginal ulceration 
extending into the connective tissue, and thence into the rectum, 
bladder or perineum, or from perforating rectal or vesical ulcers. 
We have been able to trace one fistula to ulceration of the Fal- 
lopian tube into the connective tissue and out at the skin over 
the perineum. 

The usual seat of vaginal tuberculosis is in the posterior fornix, 
which probably becomes infected by the uterine secretions. It has 
been found that peritoneal or tubal tuberculosis may, either of them, 
infect the vagina without infecting the intervening structures, al- 
though in the majority of cases the uterus also becomes infected. 

When the poison is introduced from without, the lower portion 
of the vagina may become first attacked. 

The vaginal epithelium resists the invasion of tubercle bacilli 
until it becomes injured or abraded by trauma or the presence of 
irritating fluids or secretions. 

The character of the ulceration and the fact that miliary tuber- 
cles in the vaginal walls are almost invariably connected with tuber- 
culosis elsewhere, will prevent them becoming mistaken for granular 
vaginitis. Chancres may be mistaken for tuberculous ulceration 
of the vagina, but the clinical history and course of the disease soon 
clear up all doubt. A microscopic examination may sometimes be 
required to difierentiate between it and carcinoma. 

The TREATMENT should be as radical as possible when the vagina 
alone is afiected. Excision of the diseased part and cautery of the 
wound should be done whenever practicable ; otherwise, curetting 
and cautery. When, however, as is usually the case, the uterus and 
Fallopian tubes are affected and radical measures give no hope of 
prolonging life, palliative treatment only will be indicated, such as 
astringent and antiseptic vaginal douches, local applications to 
improve the character of the ulcerations, incisions, and cleaning of 
fistulae, general tonics, etc. 

Tuberculosis of the Cervix Uteri. 

But few cases of tuberculosis of the cervix alone have been ob- 
served. The cases are also rare in which the body of the uterus is 



148 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



at the same time affected, the majority of cases being found in con- 
nection with tuberculosis of the vagina. 

It occurs in the form of miliary tubercles, ulceration, or a com- 
bination of both. It is supposed that the mucous membrane of the 
cervical cavity, which does not have the protecting pavement epi- 
thelium of the vaginal portion and vagina, can become infected 
without having a previous lesion. The first stage is one of catarrhal 
inflammation, with the presence of small tubercles under the mucous 
membrane, usually too suiall for recognition clinically. As the 
disease advances the cervix enlarges, and ulceration similar to that 
of the vagina may appear. Small-celled infiltration of the con- 
nective tissue with the characteristic giant-cells, secondary villosities 
on the folds of the arbor vitse, and enlarged glandular cavities 
are found. 

Fig. 104. 




Tuberculosis of the Cervix Uteri : g, papillse and superficial vegetation; t, connective tissue containing 
many round cells ; e, fissure in tuberculous tissue, in which mav be .seen epithelioid cells belonging 
to a tubercular follicle; c, giaut-cells ; n, epithelial covering of a gland near a tubercular follicle, 
showing large epithelial cells; o, epithelial laver formed of elongated cells; m, mucus coutained in 
the gland ; b, greatly elongated epithelial cells of a gland ; v, vessel. 

In case of development upon the vaginal portion, the granula- 
tions are for a time covered by normal layers of epithelium, the 
disease develops in the submucous connective tissue, and even 
extends slightly into the muscular layer. 



GENITAL TUBERCULOSIS. 149 

The DIAGNOSIS is based upon the presence of tuberculosis else- 
where, the severe grade of the cervical endometritis, the infiltration 
of the cervix, the characteristic ulcerations (similar to those on the 
vagina), grumous discharge, and the microscopic examination of 
the secretions and tissue, with or without the discovery of the tuber- 
cle bacilli. Tubercle bacilli are not always found in the secretions, 
but the nature of the infection can be proven by inoculation into 
the peritoneal cavity of a guinea-pig. 

The TREATMENT, in the beginning, calls for a high amputation of 
the cervix — after extensive infiltration, for a vaginal hysterectomy, 
provided, of course, other of the genital organs are not also affected. 
When extirpation is no longer possible, palliative treatment, such 
as recommended above for vaginal tuberculosis, must be depended 
upon. 

Tuberculosis of the Uterus. 

Tuberculosis of the uterus seldom occurs except in connection 
with tuberculosis of other parts. It is, however, not a rare com- 
plication of general tuberculosis, and is frequently found in connec- 
tion with tuberculous disease of the Fallopian tubes. It has been 
found in about two-thirds of all cases of genital tuberculosis. Like 
cancer of the uterus, it seldom extends below the internal os. The 
puerperal state predisposes to its development. 

Three forms are given : 1, miliary tuberculosis, with or without 
the formation of ulcerations ; 2, chronic diffuse tuberculosis (caseous 
endometritis) ; 3, chronic fibroid tuberculosis. As, however, the 
first variety occurs only as a manifestation of general tuberculosis 
or as the initial stage of diffuse tuberculosis of the uterus, without 
any definite clinical history separate from the general infection, 
and, as the third variety has not been recognized, except on the 
post-mortem table, we wall limit ourselves to the consideration of 
chronic tuberculosis or caseous endometritis. 

This form commences as a deposit or deposits of miliary tuber- 
cles in the mucous membrane just underneath the epithelium, with 
areas of inflammation over them. Microscopic examination of these 
areas shows a development of giant-cells, often containing bacilli. 
As the disease develops the epithelium is destroyed, and ulcers are 
formed with a caseous or necrotic base and surrounding infiltra- 
tion of leucocytes. In time those areas increase and unite, and 
the entire endometrium as far as, but not beyond, the internal os 



150 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

becomes the seat of caseous inflammation. The mucous membrane 
is infiltrated with small cells and destroyed, so as to be represented 
by a yellowish, caseous coating covering an ulcerated surface, studded 
with typical tuberculous nodules. The muscular tissue becomes 
hypertrophied, and at last extensively infiltrated, so as to destroy 
the firmness and resisting power of the uterine walls. When 
accompanied with stenosis of the cervical canal pyometra may 
result. 

The SYMPTOMS are first those of ordinary endometritis, with more 
or less thickening of the uterine walls. The discharge, as the dis- 
ease advances, contains cheesy matter that can often be recognized 
by the naked eye. The disease is chronic, and often associated with 
the symptoms of general tuberculosis. 

The DIAGNOSIS in the beginning may be difficult. The symptoms 
of chronic endometritis with a grumous discharge, thickened and 
enlarged uterus, salpingitis, and perhaps chronic peritonitis, should 
lead us to suspect the disease. The discovery of tubercles in any 
part of the system adds to the probability. 

A positive diagnosis, however, is usually made, only by a micro- 
scopical examination of the discharge or of the debris obtained by 
curetting. Tubercle bacilli should be sought for, but cannot always 
be found. Inoculation into the peritoneal cavity of guinea-pigs 
should give results inside of two weeks. Sterilized glycerin jelly 
may be infected by the mucus. 

According to Paul Petit, the following characteristics, discovered 
in the scrapings of the uterine cavity, prove the existence of tuber- 
culosis : " Interstitial cells which are necrosed or atrophied in a 
diffuse manner or in well-defined lines ; giant-cells in greater or 
less embryonal nodules, detached from the stroma, and apparently 
developed around the vessels, whose lumina may or may not be 
preserved ; numerous flexible and dilated glands lined with epithe- 
lial cells, which are either readily elongated or which have undergone 
an epithelioid transformation." 

Treatment. — -If the uterus alone be affected, it should be removed 
through the vagina. If the tubes are affected, they may be removed 
by an abdominal section, and the uterine body amputated at the cer- 
vix at the same time. To remove adherent tuberculous appendages 
and the entii'e uterus from above would be a difficult operation in 
most instances. There are undoubtedly cases in which both the 



GENITAL TUBERCULOSIS. 151 

uterus and the tuberculous appendages can best be removed by vagi- 
nal section. Further experience will enlighten us on this subject. 

Tuberculosis of the Fallopian Tubes. 

In the great majority of cases genital tuberculosis commences 
in the Fallopian tubes near or at their fimbriated extremity. In 
nearly all advanced cases the uterus, ovaries, or peritoneum, one or 
all, are likewise affected. Tuberculosis of the Fallopian tube may 
be primary, but it is, as a rule, secondary to peritoneal, intestinal, 
or a part of general tuberculosis. The frequency of this affection 
has only recently been brought to the attention of the profession, 
and many cases of salpingitis and pyosalpinx are turning out to be 
of tuberculous origin. The trouble, when better known, may prove 
to be quite a common one. 

Pathological Anatomy. — Tubal tuberculosis begins by the 
deposit, over a limited area or areas, of miliary tubercles immediately 
underneath the epithelium. At first these tubercles are not recog- 
nized by ordinary inspection, and often pass unnoticed when tubes 
thus affected are removed. As there are no symptoms of this stage, 
the condition is of greater scientific than practical interest. 

Tuberculous salpingitis or chronic diffuse tuberculosis of the tube 
is the form usually diagnosed. In these cases the tubercles may or 
may not spread over the entire mucous membrane of the tube. The 
overlying epithelium is destroyed, and the mucous membrane about 
the tubercles is infiltrated with epithelial cells, more extensively near 
the fimbriated end, where the tubercles are most abundant. Coagula- 
tion-necrosis takes place in spots, and may involve the whole mucous 
membrane in the destructive process, so that the membrane may be 
represented, particularly at the fimbriated end, by a mass of caseous 
material, lying over granular ragged ulcers or directly upon the mus- 
cular structure. The disease develops slowly, and remains for a long 
time limited to the mucous membrane, but in time invades the mus- 
cular wall. The fimbriated end is apt to be closed, and the secre- 
tions have the appearance of a curdy pus, consisting of mucus, cheesy 
matter, with granular and epithelial debris, and, if there be mixed 
infection, also of pus. In old cases the pus-corpuscles may be entirely 
converted into granular matter, so that neither pus nor pus-germs 
can be discovered. As much as two quarts of puriform matter 
have been found in the dilated tube, but ordinarily the quantity 
is small, and may consist of only a little grumous fluid or of almost 



152 



^iV" AMERICAN TEXT-BOOK OF GYNECOLOGY. 



solid cheesy matter, which may be partly calcified. The tubal walls 
are thickened, and become attached by dense adhesions to the pos- 
terior surface of the broad ligaments, pelvic walls, omentum, and 



Fro. 105. 




Tubercular Pyosalpinx with Tubercular Ovary. 

intestines. The adhesions and tuberculous deposits usually affect 
the ovary and surrounding peritoneum. 

The ordinary microscopic appearances of tuberculous tissue with 
inflammatory action, are usually present. In the folds of the mucous 
membrane are found giant-cells surrounded by round-cell infiltra- 
tion, tuberculous follicles, degenerating cells, etc. Tubercle bacilli 
cannot always be detected. Williams describes a chronic fibroid 
tuberculosis of the tube. He says : " It differs from the other 
forms of tuberculosis in the excessive formation of fibrous tissue 
in and between the tubercles. Sections show the lumen greatly 
distorted and a few miliary tubercles scattered through the mucosa. 



GENITAL TUBERCULOSIS. 153 

There may or may not be accompanying inflammatory changes, the 
main change consisting in the excessive development of fibrous tis- 
sue both within and without the tubercles and the relative absence 
of caseation. The marked feature of this form of tuberculosis 
appears to be its chronicity.'' 

Symptoms and Diagnosis. — The symptoms are those of ordi- 
nary salpingitis, bnt with a somewhat different clinical history. We 
would suspect a salpingitis with extensive adhesions, afternoon tem- 
perature, and signs of progressive chronic peritonitis, in a delicate 
virgin, to be tuberculous. A tuberculous family history, or the dis- 
covery of the disease in the peritoneum or in any other part of the 
system, and the absence of any other apparent cause or known 
beginning of the disease, arouses suspicion of its tuberculous cha- 
racter. Encysted ascitic fluid extending high above the pubes 
indicates tuberculosis in the majority of cases. The ovaries are 
often coincidently affected, and give the usual signs and symptoms 
of chronic ovaritis. A salpingitis in an ordinary healthy woman 
with symptoms of pelvic inflammation dating from marriage, an 
abortion or confinement, with occasional acute attacks of pelvic 
peritonitis that subside so as to leave no temperature, which recur 
as the result of over-exertion or trauma, and which are retrogres- 
sive rather than progressive as long as the patient remains quiet, 
would be considered due to other causes than tuberculosis. 

Prognosis. — The prognosis is similar to the prognosis of tuber- 
culosis elsewhere. There is always a tendency to spread to the 
peritoneum, ovary, and uterus, and finally to a general infection 
and a fatal termination. 

Treatment. — In cases of primary tuberculosis of the tubes they 
should be removed. When the disease is associated with tubercu- 
losis elsewhere, except in the ovary and peritoneum, the operation 
should only be performed in case the complicating conditions are 
quiescent and the general condition of the patient good. Tuber- 
culosis of the peritoneum, except in an advanced stage, is not a 
contraindication, since abdominal section often has a beneficial 
influence upon it. "^'^'^ 

Tuberculosis of the Ovary. 

Primary tuberculosis of the ovary has not yet been described. 
In connection with tuberculosis of the Fallopian tubes and of the 
peritoneum it occurs frequently, more often with the former, but 



154 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

has been found in a few instances as a part of general infection, 
without participation of the other organs of generation. 

It occurs in the form of miliary tubercles, caseous masses, or 
tuberculous abscesses. The miliary tubercles have usually been 
found on the surface of the ovary, and in connection with tuber- 
cular peritonitis, have been known to invade the walls of ovarian 
tumors. 

The symptoms, diagnosis, prognosis, and treatment are insep- 
arable from the tubal and peritoneal diseases with which they are 
associated. 

Tuberculosis of the Peritoneum. 

Tuberculosis of the peritoneum is met with in three varieties, 
viz : 

1. Miliary; 

2. Fibroid ; 

3. Caseous, 

The pathology is similar to that of pulmonary tuberculosis ; in 
fact, tuberculosis of the pleura is frequently associated with that of 
the peritoneum. 

The infection may come directly from the blood or from infected 
viscera by way of the lymph-channels. Tuberculous ulceration of 
the bowels is undoubtedly a frequent cause. Tuberculosis of the 
Fallopian tube is found in more than one-third of the cases among 
women, and may be either the cause or the result. 

Miliary Tuberculosis. 

Miliary tuberculosis of the peritoneum may exist in a latent 
or an acute form. It may develop in a gradual, subacute manner 
without active symptoms or with none at all, and go on to the 
development of fibroid tuberculosis, and not be discovered until the 
peritoneal cavity is opened, on account of some other disease, either 
during life or post-mortem. 

Acute miliary tuberculosis consists in a development of miliary 
tubercles in the layers of the peritoneum, with coexistent peritonitis. 
The peritoneum about the deposits may be slightly injected or of 
a raw-beef red color, with loss of the normal lustre. The tubercles 
may be confined to the intestinal coils and mesentery or may be found 
upon the parietal layer and omentum. Ascites of a deep yellow or 
bloody tinge, without adhesions, may be present, or adhesions may 



GENITAL TUBERCULOSIS. 155 

form and either limit or encapsulate the fluid. A fibrinous exudate 
is formed on the viscera after a time. The intestinal coils may become 
adherent to each other or to the parietal peritoneum. The omentum 
may be adherent to the abdominal walls or to the intestines, or to 
both. The adhesions are usually frail and bleed freely upon being 
separated, although the bleeding, which is capillary, soon stops. On 
account of the tendency to effusion the adhesions are not usually 
extensive. Tubercles may be found on some of the organs, such as 
the liver, spleen, or Fallopian tube. 

Symptoms. — The symptoms may develop suddenly or gradually. 
In the former case the patient enjoys pretty good health until over- 
taken by an attack of acute peritonitis. Prodroma, such as loss of 
appetite, disordered digestion, loss of flesh and strength, elevated 
afternoon and subnormal morning temperature, occasional abdom- 
inal pains, and perhaps tympanites, may not have been sufficient to 
attract attention. 

Upon the supervention of the acute attack, the temperature goes 
up to 102° or 103° F. in the afternoon, usually with morning 
remissions, vomiting, and sometimes diarrhea, acute abdominal 
pains and tenderness, and tympanites. The symptoms usually sub- 
side in a few days, but not completely ; some intestinal or gastric 
disorder, some afternoon temperature, some tenderness, and some- 
times a little ascites, remain. Pleuritic pains with accelerated 
respiration may complicate the symptoms. 

Usually this condition of partial cure remains for a while, and 
may be followed by a more or less complete recovery as far as the 
symptoms are concerned, or by other attacks, with development of 
the symptoms of caseous peritonitis, persistent gastric and intesti- 
nal disturbance, emaciation, and the usual general syipptoms of 
advanced stages of tuberculosis. 

In case the disease develops gradually, tympanites, abdominal 
pains and tenderness, afternoon elevation of temperature, indiges- 
tion, attacks of diarrhea, emaciation and weakness gradually 
become more pronounced and more persistent. The abdomen may 
be greatly distended and everywhere resonant, or may show evi- 
dences of ascites. These symptoms may at any time develop into 
an acute attack of general peritonitis, or gradually merge into the 
caseous variety, or exhaust the patient in the subacute stage. 

Special symptoms are often observed that have reference to 
infection of the affected viscera. Thus we may have slight icterus, 



156 ^iV^ AMERICAN TEXT-BOOK OF GYNECOLOGY. 

hepatic pain, and predominant gastric disturbance when the liver is 
affected ; pain in the iliac regions, backache, leucorrhea, metro- 
staxis, hysteria, etc. when the sexual organs are invaded. 

Pigmentation of the skin has been observed in many cases, par- 
ticularly in those of slow development and in the caseous variety, 
and is considered of diagnostic value. 

Diagnosis. — The diagnosis is based upon the prodroma or the 
gradual onset of the local symptoms, the general emaciation, and 
the presence of tuberculosis elsewhere in the system, particularly 
in the Fallopian tubes, pleura or lungs, and upon the presence 
later of ascites. The ascites is very prone to take on the appear- 
ance to the naked eye of an ovarian cyst; in other words, the 
bulging in the flanks, as occurs in other varieties of ascites, is often- 
times entirely absent, but in its place the abdomen is distended into 
a globular shape, as in cystic disease. This is of considerable prac- 
tical value from a diagnostic point of view. 

Prognosis. — The prognosis of miliary peritoneal tuberculosis 
is probably more favorable than that of any other form. Many 
patients get well under good hygienic surroundings and appro- 
priate treatment, while others are apparently cured by an ope- 
ration. 

Treatment. — The general treatment is similar to the treatment 
of tuberculosis elsewhere. Tonics, remedies for the relief of gastro- 
intestinal irritation, rest, massage, a carefully-regulated diet, diges- 
tives, creasote, counter-irritants, often lead to a cure of the perito- 
nitis, and a practical cure of the tuberculosis through fibroid 
degeneration. 

When ascites has resulted, or when miliary tuberculosis exists 
without extensive adhesions, an abdominal incision, with evacua- 
tion of the fluid if present, and the admission of air into the peri- 
toneal cavity, are often followed by a cure. 

Whether light and the dryness attending the removal of the 
fluid cause the improvement, or the removal of the ptomaines of 
the bacilli with the ascites, or the subsidence of the inflammation 
which favors the development of the germs, or the mere evacua- 
tion of the fluid with its embarrassing action upon the peritoneum 
and intestinal muscularis, is difiicult to determine. We should say 
that the removal of the fluid would be one factor in those cases in 
which ascites is present. This undoubtedly relieves mechanical 
embarrassment, removes some irritant products, and leaves the 



GENITAL TUBERCULOSIS. 157 

peritoneal absorbents in a better condition to remove the products 
of inflammation, and thus favors fibroid changes. The admis- 
sion of air would also act as a stimulant to the circulation. It 
must be remembered that many of the cases would have recovered 
without the operation, and also that the care after abdominal sec- 
tions must do much to relieve the peritoneal irritation and inflam- 
mation. 

The question of drainage after such an operation is an open one. 
If there be but little ascites and no adhesions have been separated, 
drainage can hardly be of use. Considerable ascites of rapid for- 
mation or oozing from separated adhesions would, on the contrary, 
require it. 

In long-standing cases, with fibrinous flakes and some gelatinous 
fluid that may have been encapsuled about diseased organs, the peri- 
toneal cavity should be douched out with a normal saline solution 
(0.6 per cent.). This condition, however, belongs more often to the 
caseous variety. 

Fibroid Tuberculosis. 

As miliary tuberculosis represents the first stage, so fibroid tuber- 
culosis represents the last stage, of the disease. We refer, of course, 
to those cases that do not terminate in caseation and ulceration, and 
which will be considered hereafter. 

The condition usually found is that of old; firm visceral and 
parietal adhesions and fibrous bands of greater or less extent, with 
hard nodules, sometimes whitish, but more often pigmented, from 
1 to 3 mm. in diameter, and situated either on the surface of the 
peritoneum, in the mensentery, omentum, or in the fibrous bands. 
Although tubercle bacilli may be found in them, there is a scarcity 
of tubercle cellular tissue and an abundance of fibrous tissue. The 
matting together of intestines, omentum, and other viscera may 
give rise to localized resistant masses that can be felt through the 
abdominal walls. 

Symptoms.— Oftentimes there are no symptoms except those ref- 
erable to a previous stage, and which may have been overlooked or 
misinterpreted. 

The usual symptoms are, more or less abdominal distension and 
tenderness, constipation, gastric or intestinal indigestion, emaciation, 
localized pains, and evidences of present or past tuberculosis in the 
lungs, pelvic organs, or elsewhere. The tenderness is not so great 



158 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

but that a careful Dalpation of the abdomen may be made. The 
temperature may bt* subnormal for weeks at a time, or, if there be 
much disturbance in the abdomen, may rise to 100° or even 102° F. 
in the afternoon, and fall to 97° or 98° F. in the early morning 
hours. Night-sweats are not usually persistent, if indeed present, 
unless there be also some more active form of the disease in the 
system. In many cases, however, the symptoms are complicated by 
tuberculosis of other parts, and the patient usually dies of general 
or pulmonary tuberculosis, rather than peritoneal. In many cases 
the local and general condition improves, the symptoms subside, 
and the patient recovers, and may remain in quite good health 
until a new development of the disease, either in the abdomen or 
elsewhere, takes place. 

Diagnosis. — The diagnosis is based upon the symptoms already 
given, upon the mild character of the disease, and the tendency to 
improve, instead of growing gradually worse, as in other kinds of 
tuberculosis of the abdomen. An indefinite resonant tumor or 
tumefaction of chronic character is sometimes found, unaccom- 
panied by ascites. Exudates connected with appendicitis and septic 
salpingitis are differentiated by the characteristic acute symptoms 
that precede them. The presence of tuberculosis elsewhere would 
lead us to suspect the true nature of the affection. 

Prognosis. — The prognosis is often favorable as far as the local 
condition is concerned. The chief danger lies in the presence 
of the tubercle bacilli in the system, leading to development of 
tuberculous inflammation elsewhere or in other portions of the 
abdominal cavity. Many cases, however, recover without recur- 
rence. 

Treatment. — The treatment consists mainly in promoting the 
curative process that is already going on. If there be but few 
symptoms, ordinary hygienic management, tonics, change of occu- 
pation, etc. will be sufficient. Gastro-intestinal derangement, abdom- 
inal tenderness, tympanites, and emaciation call for more careful 
treatment. The irritability of the stomach should be relieved by 
appropriate remedies, the bowels regulated, and an abundance of 
easily-digested food given. If there be much abdominal tenderness 
and tympany, the patient should be kept quiet, the circulation and 
nutrition maintained by massage and large quantities of good milk 
and cod-liver oil. Counter-irritation over the abdomen and elec- 
tricity in moderate dosage may have some beneficial influence. 



. GENITAL TUBERCULOSIS, , 159 

When the symptoms subside, active outdoor exercise and the ordi- 
nary general treatment for tuberculosis should be recommended. 
Creasote per orem and per rectum may be tried, as in cases of pul- 
monary tuberculosis. 

Caseous Tuberculosis, 

The caseous or ulcerative form of peritoneal tuberculosis gives 
rise to a variety of conditions. The parietal, visceral, and omen- 
tal peritoneum and subperitoneal glandular structure may be the 
seat of degenerating tubercles. In some cases all the abdom- 
inal viscera are agglutinated by caseous tubercular substance 
and false membranes. Sometimes the adhesions include one or 
more small accumulations of yellowish, reddish, or brownish 
serum of variable density, containing flakes of lymph-granular 
debris, and not infrequently pus and blood-corpuscles and tuber- 
cle bacilli, or the entire fluid may be puriform, or one accumu- 
lation may be serous and the other purulent. Pus-collections 
between and over agglutinated intestines or viscera may, by 
ulceration, give rise to intervisceral or external fistulse. Thus 
in children, umbilical fistulse have often been recorded ; in the 
pelvic tuberculosis of women, rectal fistulse ; while, after ope- 
ration and upon the post-mortem table, viscero-abdominal or 
intervisceral fistulse. More often this cheesy infiltration and 
agglutination of viscera is localized, in some part or parts of the 
abdominal cavity, forming a tumor-like mass. Occasionally gene- 
ral ascites coexists with localized deposits, but more often there is 
either none or there is one large, encysted accumulation, surrounded 
by a capsule of thickened and infected peritoneum and adherent 
intestines. Local abscesses may burrow through adhesions or in 
connective tissue for a long distance, and become surrounded by a 
large area of induration before finding an outlet. 

Among the favorite places for this variety of peritoneal tuber- 
culosis to show itself, are, about the liver, the csecum, the omentum, 
and the uterine appendages. 

The peritonitis about the liver is always secondary to cheesy 
tuberculosis of the liver, and is a very rare aflection. 

Agglutination of the intestines about the caecum, with cheesy 
deposits and abscess, that burrow across the abdomen, or upward or 
downward, or discharge into the rectum, has been frequently met 
with. Some of the cases described have probably been old cases 



160 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

of appendicitis either with or without secondary infection by the 
tubercle bacilli. 

Tuberculosis sometimes attacks the omentum, particularly in 
children, and may retract and roll that membrane in the shape of 
a hard tumor extending across the upper abdomen, or may go on 
to abscess-formation, and either ulcerate externally at the umbilicus 
or into an intestine, or both. 

Pelvic peritoneal tuberculosis in women is usually connected with 
tuberculous salpingitis. The peritonitis, if extensive, generally 
assumes the encysted form, one large cyst reaching up into the 
abdominal region, sometimes to the umbilicus, and almost entirely 
across, with occasionally one or two small separate sacs in the recto- 
uterine pouch and under the appendages. In these cases the append- 
ages and the surrounding exudate form a hard mass that extends from 
the uterine horns to the sides of the pelvis. The solidified append- 
ages, the uterus, upper part of the bladder, pelvic walls, lower 
anterior abdominal wall and adherent intestines are covered by a 
thick, friable, grayish, or yellowish peritoneal exudate, that can 
usually be readily separated from the intestines superiorly, but 
which often adheres firmly to the parts in the pelvis. Tubercle 
bacilli are frequently found in the tubes, and signs of tuberculosis 
may exist elsewhere in the system. 

Symptoms and Course. — Caseous tuberculosis of the peritoneum 
usually gives the history of repeated attacks of peritonitis, which 
may have been recognized as such or may have been mistaken for 
gastric or intestinal disorders, typhoid fever, pyosalpinx, appendi- 
citis, etc. Between these attacks the symptoms may subside and 
the temperature remain subnormal, particularly in the early morn- 
ing, for weeks at a time, and but little discomfort be felt. Usually, 
however, there is an afternoon rise of temperature to 100° or 
101° F., some tympany and abdominal tenderness, and occasional 
pain in the intestines or pelvis. At the same time the appetite is 
impaired, and the bowels either obstinately constipated or alter- 
nately relaxed and constipated, with attendant loss of flesh. In 
more advanced cases there may be occasional or persistent vomit- 
ing or diarrhea, great abdominal distension from intestinal gases 
or ascites, or both together, with marasmus and night-sweats. 
Obstruction of the bowels has been noted in a few cases. Pleu- 
risy is not a rare complication, and pulmonary tuberculosis will 
be detected in most cases before the fatal termination. 



GENITAL TUBERCULOSIS. 161 

In some cases the nutrition is but little impaired, and only the 
signs of local inflammatory action of the uterine appendages or 
over some other circumscribed area are to be found. 

Diagnosis. — The condition of the patient often simulates that 
of typhoid fever when the tubercles are localized about the caecum. 
The previous history of abdominal symptoms, the absence of the 
typhoid eruption, the preceding prolonged record of a moderate 
afternoon rise in temperature, palpable induration about the caecum, 
and its occasional extension out from the iliac region, tuberculosis 
elsewhere, and the continuance of symptoms after the first three or 
four weeks, with perhaps a family history of tuberculosis, will gene- 
rally help us to arrive at a definite diagnosis, although in obscure 
cases considerable time may elapse before the differences can be 
made out. 

Appendicitis has a history of short localized acute attacks with 
complete intermissions, while the preceding acute attacks of tuber- 
culosis, if severe, are less localized, or, if not severe, are of a more 
remittent character. Extensive tympanites, pronounced derange- 
ment of the intestinal secretions, and the emaciation and general 
symptoms of the tuberculous condition are not usually noticed in 
appendicitis. A mild attack with a moderate rise of temperature 
for a few days, and then a sudden lighting up of general peritoni- 
tis, is characteristic of appendicitis, as is also the localization of the 
exudate and tenderness near the anterior superior spine of the ilium, 
on a line extending from the spine to the umbilicus. 

The local signs may be confounded with malignant, or even 
benign, abdominal growths, but the general symptoms will usually 
enable us to decide in favor of tuberculosis. 

Peritonitis accompanying septic salpingitis shows more decided 
regressions, improves more by rest in bed, and has a history that 
points to its septic origin. 

Encysted tubercular peritonitis, particularly that form connected 

with tubercular salpingitis, may simulate an ovarian cyst. In the 

former case, however, we can detect the enlarged tubes per vaginam, 

and by the bimanual examination detect an intestinal tumor that is 

connected with the diseased appendages. The tumor as felt over the 

pubes is not so firm as an ovarian cyst and gives larger waves of 

fluctuation. The percussion note shades off gradually from dullness 

to resonance. The encysted fluid has not the definitely rounded 

outline of a single ovarian cyst. The afternoon rise of tempera- 
11 



162 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

ture, emaciation, and general signs of tuberculosis indicate the 
true nature of the infection. 

Thin-walled parovarian cysts often give the same kind of wavy 
fluctuation, but they are of a definite rounded outline and not con- 
nected with indurated appendages. The percussion note becomes 
resonant more abruptly. 

Peognosis. — The prognosis is usually bad. The disease is no 
longer in the first stage, and tends to local disorganization and 
general infection. A few cases are cured by operation. After a 
fecal fistula has formed an early fatal result may be expected. 

Treatment. — The medical treatment is similar to that already 
recommended for the other varieties, and can only be considered as 
palliative. The surgical treatment consists in the removal of peri- 
toneal fluid by abdominal section with such affected parts (uterine 
appendages, omentum, etc.) as may be practical, and the separation 
of such adhesions as may be necessary to evacuate local fluid accu- 
mulations and relieve intestinal paralysis or obstructions. 

The removal of the uterine appendages has already been referred 
to. The accompanying sacculated effusions should be removed so as 
to leave the cavity dry, and the false membrane sponged clean of 
all lymph and debris. Sometimes we may have to content ourselves 
with doing this, without disturbing the appendages. When the 
appendages are removed, the integrity of the sac is necessarily 
destroyed at its lower end, and it is then well to remove all of 
the sac that can be easily detached, for fear that it might undergo 
degenerative changes. 

In the first case of this kind operated upon by the author, he left 
the entire sac, excepting the portion removed with the appendages, 
and had for a result a suppuration commencing on the ninth day. 
On the twenty-seventh day a counter-opening was made in the cul- 
de-sac of Douglas. About a week after that a fecal fistula formed. 
The patient died seven weeks after the operation, with the fistula 
still discharging pus and feces. 

Profiting by this experience, the upper part of the sac was 
removed in the next case, leaving only a small, firmly adherent 
portion in the recto-uterine pouch, the drainage-tube being removed 
in fifty hours, and the patient cured. She is now, eighteen months 
after the operation, teaching school, and in better health than for 
years. 

The next case had incipient pulmonary tuberculosis, with a his- 



GENITAL TUBERCULOSIS. 163 

tory of acute attacks of pneumonia and pleurisy. In addition to a 
pint of sacculated peritoneal fluid, an abscess containing cheesy mat- 
ter was found filling the recto-uterine and lateral peritoneal cul-de- 
sac. Both tubes contained cheesy pus. The left was so friable that 
the ligatures cut completely through and could not be reapplied. 
Removed all of the sac possible. Drainage-tube used for thirty 
hours. Recovery without a bad symptom. 

When the disease is up among the intestines and the coils are 
firmly matted together, it is usually better not to separate them, for 
a fecal fistula may already have formed between them or may be pro- 
duced by the operation. Drainage is necessary in most cases, but it 
should usually be made with a glass-tube and the tube taken out 
as soon as possible. 

The good results of abdominal section even in caseous tubercu- 
losis are sometimes surprising, and many cures are recorded. Instead 
of the general peritoneum becoming infected, the healthy mem- 
brane seems to help in curing the diseased portions. 



DISEASES OF THE VULVA AND VAGINA. 



Hypeetkophy of the External Genitals. 

The parts most frequently subject to hypertrophy, whether con- 
genital or acquired, are the nymphce or labia minora. In women, 
with liberal development of subcutaneous fat, the nymphae are often 
entirely concealed by the labia majora. Ordinarily, they project 
far enough for the edges to be seen. Occasionally, however, they 
project like wings folded over the vestibule or unite over the clitoris 
to form an apron, or one or both may be divided into one, two, or 
more folds, forming double, triple, or even quadruple nymphse ; or 
one labium may be larger than the other ; or they may extend down 
and unite in front of or behind the anus, and cover up the vestibule 
so completely as to cause great annoyance, and may even require an 
operation for their removal. Among the Bushmen and Hottentots 
the labia minora often become enormously developed, and hang like 
thick aprons down to the knees. 

Inflammation may result in cases of hypertrophied nymphae 
from the friction of walking, riding, or excessive venery. Sexual 
irritation undoubtedly causes enlargement and even hypertrophy, 
but should not be considered as the usual cause. 

The remedy for these conditions consists in amputation and sew- 
ing up of the edges with fine catgut or, preferably, silkworm-gut. 

The labia majora vary greatly in size in different women, some- 
times projecting like cushions tightly pressed together, and some- 
times consisting merely of loose folds of skin on either side of the 
exposed nymphae. The latter condition is often found in very thin 
and in old women. Occasionally the labia will extend down so as 
to form a fold in front of the anus, and have even been known to 
surround the anus. A superabundance of labial fatty tissue not 
only conceals the labium minus, but sometimes seems to draw apart 
the folds that form the latter to such an extent as almost to obliter- 
ate them. 

The clitoris is relatively larger in children than in adults, because 



164 







-■J 



o 



> 







X 

I— I 
I— I 

M 




DISEASES OF THE VULVA AND VAGINA. 



165 



toward puberty the developing labia gradually project over and 
cover it. True hypertrophy of the clitoris is much less frequent 
than of the nymphse. Occasionally, however, the clitoris is found 
to attain the size of a boy's penis, with powers of erection, and when 
accompanied by adhesion of the labia may conceal the sex. An 
amputation may become necessary, on account of the abnormal 
direction of the stream of urine, friction, excoriations, interfer- 
ence with coitus, etc., particularly when occasioning trouble in 
childhood. 

Fig. 106. 




Hypertrophy of tlie Clitoris, 



Adhesions of the Labia. 

Adhesion of the labia usually occurs in infancy and in child- 
hood, and occasionally is found in adult life. It consists merely in 
an agglutination of the surfaces without loss of epithelium or 
organic union. Deficient hardening of the epithelium has been 
given as a cause, and comparison has been made with the adhesion 
of the prepuce to the glans in the male. Un cleanliness, irritating 
discharges, and mild forms of inflammation may lead to it. 

It usually causes no symptoms, but may give rise to incon- 
venience by directing the urine upward. Later, menstrual fluid 
may be retained or may be expelled with difficulty. Coitus is 
usually interfered with, although not always. A woman in labor 
in whom the vagina could not be found, although the head was 



166 AJV AMERICAN TEXT-BOOK OF GYNECOLOGY. 

down upon the perineum, was recently observed. What at first 
seemed to be the vagina was an enormously dilated urethra, through 
which the finger easily and painlessly entered the bladder, and 
through which copulation had taken place. The occluding labial 
diaphragm was punctured a little below the urethra in the median 
line, the opening torn large enough to admit two or three fingers, 
and the advancing head accomplished the rest. The paerperium 
was normal, and the parts afterward regained their natural rela- 
tionship. 

In young children it is only necessary to separate the labia forc- 
ibly, and to keep the parts cleansed and lubricated for a few days 
to prevent an immediate recurrence. In older people the best way 
is to introduce a bent sound into the vagina, just under the urethra 
where a small opening can usually be found, and to tear the labia 
asunder from within outward by dragging the sound out between 
them. When such an opening cannot be found, and the parts are 
not separable by moderate force from without, menstruation may 
be awaited. The vagina will then become filled and the labia put 
upon the stretch by the retained fluid. The bladder should be 
emptied, a sound placed in it, a finger introduced into the rectum, 
and a bistoury trocar plunged into the fluid mass, in the median line, 
a little below the urethra. The opening should then be enlarged 
until the finger can enter the vagina, when the adherent labia are 
separated. Subsequent care prevents reunion. 

Organic union of the labia, due to traumatism or ulcerative inflam- 
mation, has been known to take place and requires operative meas- 
ures similar to the last mentioned. (See " Atresia of the Vagina.") 

Vulvitis. 

There are three varieties of vulvitis, or inflammation of the 
vulva — viz. : simple, purulent, and follicular. 

Simple Vulvitis is generally caused by local irritation. Acrid 
vaginal discharges, dirt, accumulated secretions, dribbling urine, 
parasites, traumatism from scratching, friction, and masturbation 
are the most common causes. 

Increased redness, with more or less tumefaction, and watery or 
mucus discharges, are characteristic. 

Burning pain, particularly upon the passage of urine, and per- 
sistent itching are the main symptoms. 

The TREATMENT should be directed to the removal of the cause. 



PLATE XIV. 
Fig. 1. 




Hypertrophy of Kiglit Labum Majus. Fistula of Ischio-rectal Abscess, with 
Syphilitic Eruption on Buttocks. 



Fig. 2. 



r 




\ 












i 




The same. Labum suspended. Syphilitic Eruption faded, and Fistula contracted under 

specific treatment for two weeks. 



DISEASES OF THE VULVA AND VAGINA. 167 

Copious hot water, or i of 1 per cent, aqueous saline douches, 1 or 
2 per cent, carbolated aqueous douches, or acetate of lead, a tea- 
spoonful in one or two quarts of water, or a toVo or 20V0 solution 
of bichloride of mercury, are useful when acrid or fetid vao-inal 
discharges are present. Lotions of acetate of lead, carbolic acid, or 
tannin should be used externally, and may be continuously applied 
on cloths, if the patient can be kept quiet. Or, the oxide-of-zinc 
ointment, to which 5 per cent, of carbolic acid or 2 per cent, of 
menthol is added, may be frequently applied, and often gives great 
comfort and relief. The milder applications should be used in the 
beginning of the attack ; the stronger in the advanced stages. 

Purulent Vulvitis results from the same sources as simple vulvi- 
tis, and is often an advanced stage of the same. Gonorrheal infec- 
tion is a frequent cause. Direct infection by septic matter may be 
the primary cause. 

Redness, tumefaction, and a muco-purulent discharge are always 
present. In aggravated and neglected cases, eroded and ulcerated 
spots are found on the inner surfaces of the labia, and sometimes, 
excoriations on the inner surfaces of the thighs. 

The SYMPTOMS are the same as in simple vulvitis, but intensified. 
A moderate degree of febrile reaction and restlessness at night are 
often noticeable in children thus affected. 

Although the disease may pass over without treatment, it should 
not be forgotten that there is danger of progressive infection of the 
vagina, uterus, and Fallopian tubes. 

The TREATMENT must have special reference to the septic nature 
of the disease. All that would be necessary, in addition to such 
treatment as has been given for simple vulvitis, is to obtain and 
and maintain perfect cleanliness. This requires more care than 
is ordinarily understood by that term. If we could wash off the 
pus by constant irrigation with plain water, or i of 1 per cent, solu- 
tion of chloride of sodium, or wash the parts every half hour or 
hour with a saturated solution of boracic acid, the pus-microbes 
would soon be exterminated, and a mild form of simple vulvitis 
established, or a perfect cure attained. 

Warm sitz-baths in i or 1 per cent, saline solution, three or four 
times daily, are of great benefit in removing secretions. The parts 
should be bathed as nearly every hour as possible with the saline 
or boracic-acid solution until the tenderness has somewhat sub- 
sided, and then with a weak acetate-of-lead or tannic-acid solution, 



168 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



and the case treated the same as in simple vulvitis. Cloths wet 
in these solutions may be used at night instead of frequent washings. 
After the discharge is partly checked, dry pieces of absorbent cotton, 
soaked every hour or two and reapplied, after a mild astringent 
or antiseptic lotion has been used and the parts thoroughly dried, 
constitute the very best kind of dressing. 

The stronger astringents and antiseptics, such as a 2 per cent, solu- 
tion of nitrate of silver or a tot o^ solution of mercuric bichloride, are 
required only in neglected cases and those that cannot be frequently 
dressed. As the parts cannot be cared for as often in the night, the 
mercuric or silver solution may be advantageously used at bedtime. 

Follicular Vulvitis is the name given to the inflammation of the 
glands of the vulva. Sometimes the sebaceous and piliferous glands 
are enlarged and project like minute papillary elevations upon the 



Fig. 107. 







Follicular Vulvitis. 



surface of the labia and prepuce. This enlargement of the separate 
glands is produced by the distension with mucus or muco-pus, which 
may be seen to exude from them. At other times there are no dis- 
tinct elevations, and the inner surface of the vulva is covered by 
an offensive mucus or muco-purulent secretion. 

The CAUSES are : want of cleanliness, vaginal discharges, pregnancy, 
discharge from malignant disease, and a reduced state of vitality. 



PLATE XV. 




Hypertrophy of both Labia Majora, with hypertrophy of the skin over the perineum and 

buttocks and about the anus. 



DISEASES OF THE VULVA AND VAGINA. 



169 



The SYMPTOMS differ but little from those of the other forms of 
vulvitis described above. 

The TREATMENT ill mild cases is similar to that of the simple 
and purulent forms. It is, however, more often necessary to use 
the nitrate-of-silver and corrosive-sublimate solutions. The emp- 
tying of the follicles is necessary to a cure, and may be promoted 
by alkaline fomentations, pressure by means of dry absorbent-cot- 
ton pads, manual pressure, or better by puncturing with a bistoury 
or a bayonet-pointed uterine scarificator. When thus evacuated 
nitrate-of-silver solution or tincture of iodine and glycerin, in 
equal parts, may be applied. 

Inflammation and Abscess of the Vulvo-vaginal Glands. 

Purulent vulvitis or vaginitis is apt to infect the vulvo-vaginal 
or Bartholini's glands. 



Fig. 108. 



y 




Normal Vulvo-vaginal Gland. The labium majus and minus, the sphincter vaginae muscle, and the bulb 
have been partly removed on the right side in order to expose the gland : AA, section of labium majus 
and minus ; B, gland ; C, excretory duct ; C, stylet introduced into the duct ; D, glandular end of duct ; 
E, free end of duct ; F, section of bulb ; G, ascending ramus of ischium. 

The SYMPTOMS are, swelling of the deeper tissues on the inside 
of the lower part of one or both labia, usually one at a time, with 
enlargement, and often a distinct globular tumor that may vary in 
size at different times, as the gland is filled up or has emptied itself. 
In most cases there is a small area of redness around the mouth of 
the gland, just in front of the hymen or its remains, halfway up the 
side. A muco-purulent secretion may exude or be squeezed out. 
In old cases the only symptom may be an occasional filling up of 
one of the glands with a corresponding globular tumor, deeply seated 
in the labium, which persists and gives rise to local pain for a few 



170 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

days, and then discharges more or less gradually, giving no more 
trouble for the time. In such cases there is but little, if any, sur- 
rounding induration. 

The TREATMENT consists in the ordinary treatment for vulvitis, 
and in hot fomentations to relax the orifice and thus promote the 
discharge. If the tenderness be not too great, evacuation by gentle 
pressure may be attempted. Drainage by means of dilatation with 
a small probe may be adopted in obstinate cases of recurrent accu- 
mulation. 

Abscess of the gland may result from retention of pus. In this 
case the lower outer part of the labium becomes indurated, and pre- 
sents the ordinary characteristics of labial abscess. The pus may be 
evacuated into the cellular tissue of the labium and a labial abscess 
coexist. 

Excision of the whole gland and surrounding abscesses, and sew- 
ing up of the parts by deep sutures will often effect an immediate 
cure. In case the parts cannot be excised, the secreting surface 
should be destroyed by a cautery, the surrounding pus-surfaces 
curetted, and the cavity packed with iodoform gauze and absorbent 
cotton until healed. The external incision should be a large one. 

Labial Abscess has the same etiology and symptomatology as ab- 
scess in the subcutaneous connective tissue elsewhere. The labium 
becomes enlarged with a well-defined indurated mass, extending up 
and down the labium under the hairy surface. After a few days the 
phlegmon gradually undergoes softening at some particular place, 
and an area of redness appears. The affection is very painful and 
calls for energetic treatment. Cold, in the beginning, is anodyne as 
well as sedative. Later, sitz-baths, poultices, or fomentations, fre- 
quently changed, are to be used. On account of the tendency to 
spread, an early evacuation, by incision on the inner surface, is indi- 
cated. In chronic cases connected with the suppuration of the 
vulvo- vaginal gland, all of the pus-secreting surfaces and indurated 
tissue must sometimes be excised or curetted with a sharp curette, to 
get rid of deep-seated sinuses and pockets that resist ordinary treat- 
ment. 

Exanthemata of the Vulva. 

Herpes^ Eczema, and Prurigo of the vulva present similar charac- 
istics to the same symptoms in other parts of the body. 

Herpes js usually a transient affection, and requires only that the 



DISEASES OF THE VULVA AND VAGINA, 171 

parts be protected from irritation. It consists in a group or groups 
of vesicles, without any inflammation of the surrounding skin. 
The inguinal glands are occasionally tender. A saline laxative, a 
bland ointment, or a soothing lotion, and a mildly carbolated or a 
borated vaginal douche, if the vaginal discharges be irritating, will 
usually be followed in a week or ten days by a cure. A powder 
of oxide of zinc and chalk, equal parts, may be used after the vesi- 
cles break. 

Sometimes herpes occurs in the confluent form, covering the 
vulva, and lasting for ten days or two weeks. It is often connected 
with gastro-intestinal disturbances, and may return periodically. 
Uncleanliness is a prolific cause. 

Eczema is characterized by an eruption of vesicles and some 
inflammation of the underlying and surrounding skin. When the 
vesicles rupture a serous fluid exudes which tends to dry on the 
surface and form scabs. If the disease continues, the skin remains 
red, becomes thickened, and may in time assume a more or less 
cicatricial character. These conditions may spread to the neigh- 
boring skin. Itching is a prominent symptom. The itching that 
accompanies diabetes is apt to be due to eczema. 

In the acute stage, saline or mercurial laxatives, a restricted diet, 
with soothing local applications, such as bismuth powder, a lead 
lotion, cold cream, 1 per cent, carbolic-acid douches, hip-baths, or the 
benzoated oxide-of-zinc ointment with 5 or 10 per cent, of carbolic 
acid added, may be used. In obstinate cases strong solutions of car- 
bolic acid (5 per cent.), or nitrate of silver (2 per cent.), may be 
required to stimulate the circulation of the parts. The scabs and 
secretions should be washed off with almond or other unirritatino; 
soap before the ointments are applied. Saline and mercurial laxa- 
tives, digestives, iron, arsenic, etc. may be required as for eczema 
elsewhere. Dryness and cleanliness of the parts are essential, and 
friction is to be as nearly excluded as possible. 

Prurigo is a papular eruption causing distressing pruritis, and is 
difiicult of cure. The causes are not well understood, although it 
often occurs in unclean and unhealthy subjects. 

Attention to the general health and hygienic surroundings is 
imperative. The carbolized zinc ointment above referred to, with 
the addition perhaps of 2 per cent, of menthol, often affords great 
relief. From a 5 to a 10 per cent, solution of chloroform in oil of 
sweet almonds relieves the itching in some cases, and may do some- 



172 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

thing toward dissolving out the tenacious masses at the bottom of 
the papillae. A mixture of ether and alcohol (1 : 4) may be used 
for this latter purpose, or chloroform and alcohol (1 : 4) if well 
borne. 

Erysipelas and Diphtheria of the vulva should be treated upon 
the same principles as cases occurring in other parts. They are 
rare affections, and occur in most instances in puerperal women 
and new-born children. 

Gangrene of the Vulva or Noma. 

Gangrene of the vulva occurs in poorly-nourished young chil- 
dren living in unhygienic surroundings, and is exceedingly fatal. 
It begins with reddening and infiltration of one of the labia, accom- 
panied by a discharge of ichorous serum, followed by vesication 
and the formation of a grayish-green slough and rapid gangrene. 
The condition has been likened to noma in the mouth. It is a 
rare disease, produced by infection, and has been known to be 
infectious. 

If recognized early enough, the parts should be excised, and 
the resulting wound, if not favorable for obliteration by sutures, 
should be frequently disinfected with strong antiseptics and kept 
constantly moistened with a weak antiseptic solution. The vital 
powers should be sustained with alcohol, strychnia, digitalis, and 
frequent forced feeding. 

Pruritus Vulv^. 

Pruritus Vulvm is usually a symptom rather than a disease, and 
stands for an intense or persistent itching of the vulva, more often 
felt about the clitoris and vestibule, but sometimes extending to 
the surrounding parts. The itching, depending upon palpable or 
visible local inflammatory disease, is not referred to in the consid- 
eration of this affection. It is often a serious trouble, in that it is 
apt to lead young people into the habit of masturbation, but should 
not be confounded either with the irritability attendant upon that 
habit or wdth nymphomania. 

The causes may be reflex or local. Irritating and indigesti- 
ble foods or drinks may bring on the attacks in some cases by 
reflex action or by vitiating the urine. The rubbing of clothes, 
the friction of walking, and heat of the bed act as exciting causes 
in those predisposed to it. Local congestion, such as occurs about 



CD 
pi 

< 

t — ' 
<J 
O 

< 






I— I 



DISEASES OF THE VULVA AND VAGINA, 173 

the menstrual period in certain cases of pelvic inflammation, or in 
early pregnancy, or at the end of pregnancy when the vulval and 
vaginal veins are distended by pressure above, or in old people 
with dilated veins, is an occasional cause. Constipation, sedentary 
habits, portal congestion, oedema, etc., favor it. Irritating dis- 
charges, though scanty, from follicular cervicitis, carcinoma, 
uterine sarcoma, diabetes, and incontinence of urine, are some- 
times responsible. Parasites may also act in the same way. 

The DIAGNOSIS is based upon the intermittent character of the 
itching, the absence of local inflammatory or eruptive disease, and 
the discovery of one of the above-mentioned or other remote causes. 
Oftentimes no cause whatever can be detected. The local symptoms 
are a shiny, red, somewhat oedematous appearance of the parts about 
the vestibule, with perhaps some serous secretion. Later, changes 
may occur as the effect of scratching, such as excoriations, thicken- 
ing of the nymphse, dryness, cicatricial spots, and furuncles. 

The TEEATMENT sliould of coursc depend upon the cause, which 
must, if possible, be removed. When dependent upon diabetes or 
incontinence, the parts should be protected from contact with the 
urine by some powder or ointment kept constantly applied, such as 
bismuth subnitrate, unguentum resinse, or a benzoated oxide-of-zinc 
ointment containing a 5 or 10 per cent, solution of carbolic acid. 
When from irritating vaginal discharges, the applications may 
be used with antiseptic vaginal douches and vulval washes, 
such as 1 : 2000 aqueous solution of mercuric bichloride or 2 per 
cent, carbolic acid. Skene highly recommends a 1 : 500 solution 
of the bichloride in emulsion of bitter almonds. When due to 
venous congestion, astringents act beneficially, such as lead, in 
washes and in vaginal douches, a 1 or 2 per cent, solution of 
nitrate of silver in water, or the oxide-of-zinc powder, strong or 
diluted with an equal quantity of chalk. General debility, gastro- 
intestinal derangements, uncleanliness, and the like should be faith- 
fully attended to. To relieve the itching many remedies have been 
used. The benzoated oxide-of-zinc ointment, with the addition of 
10 per cent, carbolic acid or 5 per cent, of menthol, is useful. A 
10 per cent, emulsion of chloroform in olive oil or a 5 per cent, 
aqueous solution of cocaine gives temporary relief The treatment 
is of necessity often empirical. Many patients suffer continuously 
for years w^ithout obtaining relief Under the most favorable cir- 
cumstances a cure is difficult and is only obtained by persistent 



174 



AN AMEBIC AN TEXT-BOOK OF GYNECOLOGY. 



attention to the details of treatment. Cleanliness, dryness, and 
a minimum amount of friction add materially to the desired result. 

Specific Diseases of the Vulva. 

Gonorrlieal Vulvitis is an inflammation of the vulva caused by 
the specific germ of gonorrhea, and may be considered as a part of 
specific or gonorrheal vaginitis. 

Syphilitic Affections of the Vulva occur in the form of chancres, 
mucus-patches, and syphilitic skin eruptions. The chancre has a 
dark-red surface, is sharply defined, is not excavated, is not tender 
or itchy, is single, with a hard base, and presents firm resistance 

Fig. 109. 




Simple Vegetations of the Vulva. 



to the fingers grasping it from the sides. Inguinal glands are ordi- 
narily enlarged without much tenderness. 

The ulcerations or eruptions following vulvitis are itchy, tender, 
somewhat excavated, and have not a firm base, except in connection 
with surrounding infiltration. Mucus-patches, gummata, and the 
skin eruptions exist in connection with other manifestations of 
syphilis, and have the same characteristics as those occurring else- 
where. The inguinal glands may be tender, but do not become 



DISEASES OF THE VULVA AND VAGINA, 



lib 



greatly enlarged. A chancre may ulcerate at its centre, but pre- 
serves its characteristics at the edges. 

The Chancroid is multiple, has sharply-defined edges, suppurates 
freely, has a soft yellowish or greenish fissured base, and is usually 
accompanied by a large, tender inguinal gland, with tendency to 
suppuration. The sharp edges and yellowish or greenish base dis- 
tinguish it from other ulcerations or eruptions. They should be 
treated by cauterization, iodoform, and frequent antiseptic lotions. 

Venereal Warts are the result of venereal or unclean genital dis- 
charges. They consist in irregular masses of papillomata about the 
anus or vulva. Vaginal douches of 1 : 2000 bichloride of mercury, 
frequent washings with the same, the constant application of the 
oxide-of-zinc ointment with 10 per cent, carbolic acid, or of resin 
cerate, will occasionally result in a cure. Cauterization with nitro- 
muriatic acid is usually effective. When much elevated above the 
surface of the skin (condylomata), they should be cut off and the 
base cauterized. 

Injuries of the Vulva. 

Injuries to the external genitals in women and children from 
blows, falls from elevated places upon the end of stakes,, pitchforks, 
backs of chairs, fences, etc. sometimes prove serious from the hem- 
orrhage that is liable to follow injury of the corpora cavernosa. 



Fig. 110. 




Plexus of Veins of the Vestibule. 



The first marital embraces, and even brutal kicks by intoxicated 
husbands, have produced extensive contusions and lacerations. 



176 AN AMEBICAN TEXT-BOOK OF GYNECOLOGY. 

Contusions should be treated as those occurring elsewhere in the 
cutaneous tissue. Lacerations should be sutured with deep stitches, 
so as to close up all deep veins, and thus prevent extravasations of 
blood and subsequent abscess. 

Hematoma of the Vulva. 

HewMoma of the vulva occurs in the puerperal state as the 
result of the pressure of the head during labor, or in the non- 
puerperal state, from blows or fine punctures, producing a lesion 
of a vein in the corpus cavernosus. It is usually unilateral. 

When found after labor it may be as large as the fist or larger, 
but is seldom half as large under other circumstances. It is felt as 
an elastic globular tumor in the labium, without much heat or ten- 
derness, and unaffected by coughing or increased intra-abdominal 
pressure made by the patient. Often the first sign is a feeling of 
discomfort in the part, and the accidental discovery by the patient 
of the enlargement. In other cases a sudden burning pain is 
felt, followed by a feeling of tension and a desire to urinate or 
defecate. 

The hematoma either is gradually absorbed, remains for a long 
time encysted, or undergoes the suppurative process. 

An hematoma larger than a walnut, detected as soon as, or before 
the bleeding has stopped, is best treated by an incision between the 
labium majus and minus, a clearing out and disinfection of the 
cavity, and suturing so as to include the vessels and close the 
wound completely. A small effusion may be treated by the appli- 
cation of an ice-bag in the hope of preventing an increase. After 
the hematoma has formed and shows no sign of growing larger, it 
may be let alone with the expectation that it will be absorbed. 
When it has become encysted the patient may choose between hav- 
ing the cyst excised or waiting for a tedious length of time for slow 
absorption. To excise, evacuate, and pack the cyst with gauze, 
usually means a slowly-contracting cavity or an abscess; hence it is 
always well to enucleate or dissect out the cyst-wall and close the 
wound completely with deep sutures. After suppuration has com- 
menced the abscess should be opened without delay, and, if possible, 
the abscess- wall excised and the wound sutured with antiseptic pre- 
cautions. When the facilities for such treatment are wanting, 
incision, disinfection, and packing with gauze is the next best pro- 
cedure. 



DISEASES OF THE VULVA AND VAGINA, 177 

Varicose Veins of the Vulva may be caused by pressure upon the 
pelvic veins by the pregnant uterus, intra-pelvic tumors or accumu- 
lations, or, in those predisposed to it, particularly in hot climates, 
by constipation, straining at stool, or occupations requiring constant 
standing with the exertion of intra-abdominal pressure. 

During pregnancy they may form a swelling as large as the fist, 
and may rupture during labor, causing a large hematoma. 

In the non-puerperal state they cause a slight swelling of one 
or both of the labia, or can be seen on the inner surfaces, often 
extending into the pelvis. 

They either give rise to no trouble or produce a feeling of burn- 
ning, an itching or fulness, with perhaps a slight desire to urinate. 

Astringent washes, vulval pads under a T-bandage, rest in the 
recumbent position for a few hours each day, and the avoidance of 
standing, leaning over and lifting, are helpful. The bowels should 
be well regulated, and the general nutrition and vigor of the patient 
promoted by tonics, massage, moderate exercise, fatty foods, etc. 

When a varicose vein ruptures compression will usually control 
the hemorrhage temporarily, but, as it is pretty sure to return after 
the pressure is removed, the ligature should be resorted to. 

Hydrocele of the Labium Majus. 

Hydrocele in the female is a rare affection, and usually consists 
in a prolongation of the peritoneal pouch (canal of Nuck) along 
the round ligament, through the inguinal canal, to the mons Veneris 
and into the tissues of the labium majus. Usually the sac closes 
by adhesion of the peritoneal surfaces at the internal abdominal 
ring. The labium, particularly the upper part, is enlarged, as in the 
case of hernia, but with less fulness at the external abdominal ring. 
If the communication with the abdominal cavity be not obliterated, 
the swelling disappears when pressed, and may be felt to vary in size 
with increase or decrease of abdominal pressure (coughing, etc.). 
Usually, however, the tumor is elastic, translucent, and yields clear 
serum upon aspiration. It is tio^ tender to moderate pressure. When 
the tumor is reducible a truss may be worn. When not reducible it 
may be aspirated. If it fills again, it should be evacuated, and 
obliterated by an injection of tincture of iodine. If this does not 
cure it, the entire sac should be dissected out and the parts sutured 
with silkworm gut. 

12 



178 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



Pudendal Hernia. 

Pudendal Hernia (hernia labialis inguinalis) corresponds to 
scrotal hernia in the male. The canal of Nuck and the ingui- 
nal canal become dilated, and the intestine and peritoneum are 
forced along the round ligament to the external ring and into the 
labium majus. A rounded tumor is felt in the upper part of the 
labium, prolonged into the inguinal ring, soft, insensitive to pres- 
sure, compressible, sometimes resonant upon percussion, and usually 
disappearing entirely, with a gurgling sound, if the patient be placed 
in the knee-chest position. It is very seldom strangulated. The 
omentum, and, very rarely, the ovary may be found in the sac. 



Fig. hi. 




Hernia Labialis Inguinalis and Uterine Prolapse. 

It is differentiated from a distended vulvo-vaginal gland, in 
that the latter is well down in the labium, is tense, tender, irre- 
ducible, and cannot be traced upward. Vulval abscesses are tender 
and surrounded bv indurated tissue. 

The TREATMENT cousists in a replacement and the adjustment 
of a truss with a perineal strap to pass over the labium. A descrip- 
tion of the operations for strangulated hernia and permanent closure 
of the inguinal canal belongs to works on general surgery. 

Posterior Pudendal Hernia (hernia vaginalis labialis) has been 
observed a few times. It appears in the posterior portion of the 



DISEASES OF THE VULVA AND VAGINA. 



179 



labium majus, and consists in a defect in the pelvic fascia anterior 
to the broad ligament, with descent of the contents of the abdominal 
fascia along the vagina into the labial tissues. 



Fig. 112. 




Hernia Vaginalis Labialis. 



The DIAGNOSIS is made in the same way as for the ordinary 
pudendal hernia, excepting that the contents extend under the 



Fig. 113. 




Hernia Vaginalis Labialis, extending into tlie Labium Major. 



pubic ramus. Stoltz was able to feel the defect in the fascia and 
levator ani through which the protrusion occurred. According to 



180 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



experience, pessaries and operations are useless. A belt with a pad 
attached to a stem may be adjusted. 

Tumors of the Vulva. 

Elephantiasis. — Elephantiasis occasionally affects the external 
genitals of the female, and exhibits the same characteristics cJS tliat 
occurring in the skin elsewhere. It usually atiects the entire vulva, 
and in tropical countries has been known to form a large tumor 
hanging between the thighs. 

The DIAGNOSIS is made by the fact that the swelling affects the 
skin itself and cannot be separated from it, as in fibroma, lipoma, and 

Fig. 114. 




Elephantiasis of the Labia. 

cystoma. Venereal warts are implanted upon soft natural skin, 
while the papillary excrescences of elephantiasis grow upon thick- 
ened, indurated skin. 

Malignant tumors are accompanied by deep-seated induration, 
and more ulceration in proportion to the enlargement; they run a 



DISEASES OF THE VULVA AND VAGINA. 



181 



malignant course, while elephantiasis never kills. Lupus has 
more discoloration, deeper-seated induration, and ulcerates more 
extensively. 

The TREATMENT cousists in removal of the mass and suturing 
the wound. 

Fibroids of the Vulva occur most frequently in the labia majora, 
but have been observed in the labia minora and perineum. They 
are hard, well defined, insensitive, and movable under the skin, 
unless developed in the cutaneous connective tissue, when they 
project and even b.^^^ome pendulous. They may undergo cystic 
degeneration. Sometimes they become quite large and the skin 
over them ulcerates. 

Fig. 115. 




Fibroid of the Left Labium Majus. 



They should be removed by the- knife as soon as discovered. 

Vulval Cysts are usually distended glands found in the labia 
majora, and may be single or multiple, deep-seated or superficial, 
varying from the size of a pea to that of a walnut or an egg, and 
occasionally larger. They are easily recognized as elastic bodies 
that yield a serous fluid upon aspiration. Usually they enlarge in 
a downward direction. 



182 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



The best treatment consists in the removal of the entire sac by 
dissecting it from its connective-tissue surroundings, and closure of 
the wound by deep sutures. 



Fig. 116. 




Cyst of Right Labia Majora. 



Cystic tumors of the clitoris have been met with a few times. 
They usually contain a bloody fluid. Sometimes they gradually 



Fig. 117. 




Cystic Tumor of the Clitoris, containing twenty-two ounces of fluid. 



DISEASES OF THE VULVA AND VAGINA. 



183 



shrivel up, after having their contents evacuated, and at other times 
they require amputation. Sometimes they attain a moderate size, 
and then stop growing, and the patient may prefer to have nothing 
done, as in Emmet's case. 



Fig. 118. 




Tumor of the Clitoris. 



Lipoma of the Vulva. 

Fatty tumors may occur in the vulval, as well as in other fatty 
tissue. Usually they are somewhat soft, and when a large size is 
attained, give a sense of fluctuation to the percussing finger. They 
are a little softer than fibroids, but the skin is somewhat hypertro- 
phied, and is apt to be contracted in spots, corresponding to depres- 
sions between the lobules of the tumor. They may resemble ele- 
phantiasis, but fluctuate more distinctly. 

Fig. 119. 




Adipose Tumor of the Left Labium. 



184 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The TREATMENT consists in removal by the knife. 

Occasional cases of Neuroma, Eochondroma, Melanoma, and 
Angioma of the Vulva have been observed, but their occurrence 
is so rare that a description is here superfluous. They should be 
removed the same as if found elsewhere in the body. 

COCCYGODYNIA. 

Coccygodynia is the name given to pain in the coccyx, induced by 
motion of the part, whether from external pressure or contraction 
of the muscles attached to it. 

The disease consists usually of a local arthritis. Not infrequently 
there is a rigidity or ankylosis of the joints, with dislocation or frac- 
ture, forming an artificial joint. Necrosis sometimes results. 

Parturition in old primiparee in whom the articulations have 
become rigid, and falls or blows upon the coccyx, are the ordinary 
causes. Rheumatism may possibly produce it. The principal symp- 
tom is pain in the coccyx upon sitting down, getting up or chang- 
ing position. Any posture in which the coccyx is pressed up, or 
which calls into play its attached muscles, is intolerable. Sexual 
intercourse and straining at stool are apt to be painful. The dis- 
ease is diagnosed by taking the coccyx between the finger, intro- 
duced into the rectum, and the thumb placed between the nates, 
and moving the bone, thus bringing on the pain. 

Under certain circumstances the prognosis is favorable, although 
several months, or even years may elapse before all sensitiveness 
will subside. 

The TREATMENT must bc conducted upon the same principles 
as in a traumatic arthritis elsewhere. First, the avoidance of all 
motion of the joints or pressure upon the bone. Rest on the side, 
air-cushions to sit upon, with great care in sitting down, getting up, 
leaning over, or twisting the trunk, so as to avoid producing the 
pain, are items of prime importance. Leeching and cold applica- 
tions in the acute stage, counter-irritation and alterative applica- 
tions in the subacute and chronic stages, are beneficial. 

In neglected cases, subcutaneous tenotomy or extirpation must 
occasionally be resorted to. 

Tenotomy is performed by introducing a tenotome under the 
skin at the end of the coccyx, pushing it along the side of the 
bone, and severing the entire muscular attachment, first on one 
side and then on the other, and finally at the lower end. The 



DISEASES OF THE VULVA AND VAGINA. 185 

relief afforded is great, but often only temporary, on account of 
the reunion of the severed parts. 

Extirpation is accomplished by a longitudinal incision down to 
the bone, amputation through the second joint, and severance of the 
attachments ; or the attachments may be severed first, the coccyx 
dislocated backward, and the entire bone removed. 

VULVO-VAGINAL HYPERESTHESIA AND VAGINISMUS. 

Vulvo-vaginal Hypei^esthesia consists in an extreme sensitiveness 
of a part, or of all parts, of the vulvo-vaginal entrance, except the 
labia majora. 

In some cases there is a congested appearance of the parts, or 
even inflammation and erosion ; in others there is nothing abnor- 
mal to be seen. The pathological conditions sometimes consist in 
inflammation of the inner genital organs, with or without irritating 
discharges, or in a disordered state of nutrition and enervation. 
Inflammation about the hymen or cicatricial contractions about the 
carunculse cause the most severe forms. 

The most noticeable symptom is sudden flinching or a manifes- 
tation of pain upon the least touch of the parts, although if the 
finger can be placed quietly on the hymen or in the vagina and 
left there, the complaints soon cease until some motion is made, 
when they begin again. Coitus may be excessively painful or not 
tolerated at all. Anything that alarms the patient, or even calls 
her attention to the condition, increases the difficulty. 

The TREATMENT consists in removing all inflammatory condi- 
tions, if such exist, by the means recommended elsewhere. Sooth- 
ing or anesthetic washes or ointments, such as a 5 or 10 per cent, 
solution of cocaine, or half that strength of menthol in cerate, or 
oxide-of-zinc ointment, may be used previous to all manipulations 
and at other times when discomfort is felt. Sometimes a 5 per cent, 
solution of nitrate of silver or strong carbolic acid applied once a 
week is useful to cure erosions or ulcerations. 

A valuable means of diminishing, and sometimes of curing the 
trouble in mild cases consists in introducing a bivalve speculum two 
or three times weekly, and slowly, almost insensibly, stretching the 
vagina and vaginal entrance until decided discomfort, but not severe 
pain, is felt, and then in placing a pledget of wool in the upper part 
of the vagina and leaving it for twenty-four or thirty-six hours. The 
pledget should be small at first, but gradually increased in size until 



186 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



the vagina is well tamponed. It is preferable to place a small cot- 
ton pledget saturated in a 50 per cent, solution of boro-glyceride 
against the cervix, and the dry wool below it, but not low enough 
to press at the vaginal entrance, An uncomfortably tight vaginal 
packing or rough or painful treatment or manipulation in the begin- 
ning might antagonize the patient and make her worse. Mildly 
stimulating and antiseptic vaginal douches, such as 2 per cent, car- 
bolic acid or 1 : 200 to 1 : 500 solutions of permagnate of potassium, 
often help to render the vulvo-vaginal nerves tolerant. A general 
tonic treatment is of great benefit in many cases. 

Vaginismus is a vulvo-vaginal anesthesia of an aggravated cha- 
racter, with peculiar painful, spasmodic contractions of the perineal 
and levator ani muscles. The causes of both affections are similar, 
but small spots of erosion about the vaginal entrance, or a dis- 
eased condition of the hymen or its remains are more frequently 
found in vaginismus. Frequently no cause whatsoever can be 
discovered. 

Fig. 120. 




Fibro-papillary Hypertrophy of the Hymen in a case of Vaginismus. 

Coitus is seldom tolerated, and the attempt causes a firm clo- 
sure of the vagina by the contraction of the constrictores cunni 
et vaginae. A vaginal examination is often impossible until the 
patient is anesthetized, when the orifice becomes relaxed. 

In mild cases the treatment given above for vulvo-vaginal 
anesthesia may be tried, especially the vaginal packing. Some- 
times a thorough stretching under anesthetics, with the subsequent 
daily introduction of a glass plug dilator, will effect a cure. The 
stretching can be accomplished by introducing a large bivalve spec- 
ulum, separating its blades widely, and withdrawing it quite rapidly. 



DISEASES OF THE VULVA AND VAGINA, 187 

The glass plug is the shape of a widened test-tube, about 2h inches 
in diameter, and should be worn four or five hours a day for a few 
days, then two or three hours a day for several weeks. 

In a few cases it may become necessary to practise J. Marion 
Sims's plan of excising the hymen and cutting deeply in(o the con- 
strictor cunni and edge of the levator ani on either side, so as to 
completely relax the vaginal entrance. 

Fig. 121. 




Sims's Vaginal Dilator. 

The plug should then be worn almost constantly for a few days, 
then two or three hours daily for ten days or two weeks. Inter- 
course should not be allowed until the wounds have been for some 
time entirely healed. 

Imperforate Hymen. 

As the symptoms of imperforate hymen are the same as in many 
cases of atresia of the vagina, it will be appropriate to consider both 
of the affections under the latter head in 2^. 

Atresia of the Vagina. 

Atresia of the Vagina may be congenital or acquired, and may 
involve any part or all of the vagina, from the hymen to the cervix. 

Causes. — The congenital variety arises from some pathological 
condition, usually inflammation, that has existed before birth, caus- 
ing adhesion of the mucous surfaces of the hymen or vagina. After 
birth it may be caused by septic or gangrenous vulvitis, or inflam- 
mation connected with diphtheria, typhoid fever, scarlatina, or 
measles, or by destruction of the vaginal epithelium or walls, fol- 
lowing the introduction of chemical or mechanical agents. In 
such cases either adhesion of the walls or cicatricial contraction in 
the ulcerated or sloughing parts occurs. Sloughing after labor, 
resulting in circumscribed or complete loss of the vaginal walls, is 
accountable for quite a large proportion of cases. Non -puerperal 
traumatisms also enter as a causative factor. 



188 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



Varieties. — The places of obstruction may be low down, con- 
sisting either of an imperforate or impervious hymen, or of the 
occlusion of the lower end of the vagina. The obstruction may 
be in the middle or upper portion or in different portions of the 
viscus, or it may involve the whole canal. Another variety con- 
sists in a double vagina and uterus, one side of which ends in a 
blind sac above the hymen. In many cases the condition is one of 
stenosis instead of complete obstruction. 



Fig. 122. 




Atresia of the Hymen. 

Complete or extensive congenital obstruction of the vagina is 
generally found in connection with deficient development of the 
uterus and ovaries. 

Course. — Obstruction at or near the hymen may be accompanied 
by a retention of mucus in early life, and of the menstrual fluid in 
later life, particularly if the development of the uterus and ovaries 
has not been interfered with. The vao-ina becomes dilated and 
hypertrophied, and sometimes also the cervix, uterus, and Fallo- 
pian tubes. These latter are more often dilated when the atresia 
involves the upper portion of the vagina, and in such cases pelvic 
peritonitis often ensues with adhesions, and occasionally rupture of 
the tubes. 

When there is occlusion of the lower end of one side of a dou- 
ble vagina and uterus, the occluded side is most liable to burst 
into the other side, particularly through the cervical septum. The 



DISEASES OF THE VULVA AND VAGINA. 



189 



tissues then become infected, and develop into a pyokolpos or pyo- 
metra. The dilated Fallopian tube has also been observed to 
burst into the peritoneal cavity. 

Fig. 123. 




Complete Occlusion of the Vagina : v, vagina ; ou, uterus. 

Symptoms. — The deformity may be discovered in early life, but 
the symptoms do not usually appear until after puberty. Amen- 
orrhea is as a rule the first. Recurrent menstrual pains are felt 
each month, but attention may not be called to the condition until 
the patient marries and finds copulation to be impossible. After con- 
siderable accumulation has taken place, pressure upon the bladder 
or rectum may cause pain in these organs and interfere with their 
normal action. Later, the symptoms of pelvic peritonitis, pelvic 
hematocele, or septicemia may be added, in connection with the 
development of hematosalpinx, and rupture of the uterus or tube, 
or of pyometra and pyosalpinx. 

Diagnosis in Case of Imperforate Hymen. — Physical exam- 
ination reveals an absence of the vaginal entrance and the presence 



190 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



of an elastic swelling under the pubic arch, which sooner or later 
can be detected over the pubes. Obscure fluctuation or a feeling 
of elastic continuity is then recognized if one hand be placed over 
the , pubes and another upon the swelling below, whether from its 
vulval aspect or by rectal indigitation. The finger in the rectum 
recognizes an elastic globular tumor partially or completely filling 
the pelvis. A catheter in the urethra passes in front of the mass. 



Fig. 124. 




Hypertrophied Vaginal Walls above an Atresia of the Vagina. 

There is but little tenderness of the parts except at the time of 
the menstrual pains. 

Stenosis, or incomplete obstruction, is known by the fact that an 
occasional escape of the . menstrual fluid occurs. A careful exam- 
ination, particularly under an anesthetic, will usually lead to the 
discovery of a small opening. The opening is sometimes found 
just under the urethra, pointing upward, and is most easily located 
by means of a fine bent probe. 

Congenital atresia is nearly always discovered at or near puberty, 
if not earlier. The acquired forms often show some irregular con- 
tractions or cicatrices due to past inflammation. Cicatrices are 
made more noticable by hooking a finger in the anus and putting 
the perineum on the stretch. 



DISEASES OF THE VULVA AND VAGINA, 



191 



Occlusion of the lower end of the vagina gives rise to the supra- 
pubic tumor, but is not accompanied by the elastic vulval swelling. 
The finger in the rectum and the sound in the bladder enable us 
to feel just how far down toward the vulva the retention tumor 



Fig. 125. 




Double Uterus and Double Vagina, with Retention of Menstrual Fluid on the Left Side. 

reaches. When the whole vagina is occluded the bimanual rectal 
examination discovers the enlaro^ement to be uterine and the vagina 
to be collapsed or in the form of a fibrous cord. When the occlu- 
sion is in the upper part of the vagina, its upper end is discovered 
by the same bimanual examination, and the lower end by the finger, 
or sound in the vagina introduced while the finger is still in the 
rectum. 

On account of the uterine enlargement it is difiicult to recognize 
the dilated tubes, although an anesthetic will sometimes enable us 
to do so. 

Occlusion of one side of a double vagina is not accompanied by 
amenorrhea. The other symptoms, as well as the signs obtained 
by rectal and abdominal examination, are much the same as in 
cases of single vagina. The finger in the vagina, however, dis- 
covers a rounded tumor projecting into it from one side and flat- 
tening the cervix, so as to render the os somewhat crescentic in 
shape, with the concavity toward the affected side. If the 
tumor be aspirated from the vagina, a tarry fluid will be with- 
drawn, proving its nature. When there has been a perforation in 
the cervical region, pyokolpos and pyometra will usually have 
resulted. The tumor is less firm, and pressure upon it generally 
causes pus to flow into and out of the vagina. There will be septic 
symptoms, with occasional discharges of pus per vaginam, giving 



192 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

temporary relief. If rupture of the septum does not occur, the 
mass may finally project through the vulva and give the appear- 
ance of a prolapse of the vagina or a cyst of the vaginal wall. 

Prognosis. — Without interference the prognosis is, as a rule, 
bad. Dilatation of the uterus and Fallopian tubes, with pelvic 
peritonitis and adhesions, and occasionally rupture of the Fal- 
lopian tubes, pelvic hematocele, and even death, follow. Distor- 
tion of the organs concerned, with permanent destruction of their 
functions, is the rule when interference is delayed. Bursting exter- 
nally, excepting in the cases of double vagina, seldom occurs, and 
even then only after irremediable damage is done to the organs of 
procreation. 

Treatment. — The only rational treatment consists in evacuation 
of the fluid, and this should be done as early as possible after its 
discovery. The danger connected with the operation is threefold — 
viz. (1) danger of intraperitoneal rupture of a dilated and adherent 
Fallopian tube, as the vagina contracts ; (2) of sepsis due to infec- 
tion of the contents through the opening made; and (3) of injury 
of the bladder and rectum during the operation. 

In cases of occlusion at or near the hymen, in which the accumu- 
lation is only recent, the second danger — viz. sepsis — is the only one 
to be feared. When the accumulation is of long standing and forms 
a large suprapubic tumor, the first danger — viz. rupture of a Fal- 
lopian tube — is to be guarded against. The best way is to make a 
small opening into the mass and allow the contents to flow away 
gradually, taking from one to two or three hours ; then to enlarge 
the opening by a crucial incision and wash out the sac with a great 
quantity of sterilized saline solution (I of 1 per cent.), and pack 
the vagina loosely with iodoform gauze. In no instance should a 
long time elapse between opening and cleaning out, for fear of 
serious or fatal septicemia. Aseptic and antiseptic precautions must 
be observed throughout. 

The gauze should be removed in twenty-four hours, and the cav- 
ity thoroughly washed out with a mild antiseptic solution, such as a 
1 per cent, carbolic-acid solution, twice daily. The tendency to con- 
traction of the opening may be combated by having the patient wear 
glass plug part of the time. 

When the atresia is higher up in the vagina, all three of the 
dangers above mentioned are to be guarded against. It is necessary to 
dissect with the scalpel and finger, using the latter as much as possi- 



DISEASES OF THE VULVA AND VAGINA, 19a 

ble, between the bladder and rectum, toward the tumor. A finger 
should be kept in the rectum as much of the time as possible for a 
guide, and the bladder held out of the way by a catheter or sound. 
As soon as the tumor is felt through the new opening, a trocar should 
be pushed into it, and the contents allowed to ooze out very slowly, 
and then the opening enlarged by small cuts with a probe-pointed 
bistoury and moderate stretching with the finger. 

Puncture through the rectum or bladder may be resorted to when 
it is impossible to operate safely by way of the vagina, but these are 
makeshift methods attended with danger from sepsis, and should 
only be resorted to in case of absolute necessity. They are, how- 
ever, preferable to a let-alone policy. 

Retention in one side of a double vagina should be treated on 
the same principles as the varieties already mentioned. The evacu- 
ation should be provided for through the vaginal septum. Excision 
of a portion or all of the septum is the surest way of effecting a 
complete cure. 

Vaginitis. 

The vaginal membrane partakes more of the character of skin 
than of mucous membrane. On account of its protected situation 
the horny layer is not well developed, except in some cases in which 
the membrane protrudes continuously through the vulva. At the 
upper end, however, it partakes a little more of the character of 
mucous membrane, in that it here contains a few muciparous glands. 
This dermoid character enables it, in its normal state, to resist infec- 
tion by the various pathogenic bacteria that enter it. 

Etiology. — Any influence, however, which injures the vaginal 
epithelium, such as the long-continued friction of foreign bodies or 
chemically irritating secretions or injecta, diminishes or annihilates 
this resisting power. If accompanied by a lack of drainage and 
consequent accumulation of secretions, the microbes multiply, infec- 
tion follows, and vaginitis finally results. 

Irritation, instead of exciting inflammation, merely leads to an 
increase in the density of the epithelium, with increased resisting 
power, as is the case with cutaneous irritation. Even a local loss 
of epithelium is not accompanied by an extension of the inflam- 
mation, provided the secretions find a ready outlet or are kept 
washed out. 

Disordered states of the general system, such as anemia, chloro- 

13 



194 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



sis, indigestion, constipation, and conditions which tend to produce 
unhealthy conditions of the skin, predispose to vaginitis. Preg- 
nancy, abdominal tumors, and any condition that produces pelvic 
congestion, whether venous or arterial, may also be considered as 
predisposing causes, and are to be taken into account in the treat- 
ment. Pregnancy acts both by producing venous congestion and 
oedema and by increasing the activity of the secretions. Secretions 
retained by a tight hymen may become infected and overcome the 
resistance of the pavement epithelium^ Pin-worms, masturbation, 
and other causes of uncleanliness may have a similar effect. Patho- 
genic secretions from the uterus, urethra, vulva, or introduced from 
without are frequent causes. Gonorrheal pus is undoubtedly the 
most common cause in adults. That the vagina may become infected 
it is necessary that the epithelium have suffered injury or that 
stagnant secretions remain in contact a long time. Inflammatoty 
action and infection may also be spread by contiguity of surface 
from the cervix or vulva. 

The exanthemata are held accountable for a small share of the 



cases. 



Varieties. — Vaginitis may be conveniently considered under 
the following heads : Simple, Gonorrheal, Granular, Adhesive, 
Emphysematous, Vesicular, and Cystic. 



Fig. 126. 




Simple Vaginitis. 

Pathology. — Simple and Gonorrheal Vaginitis in the acute 
form present the following changes : hyperemia, with redness, 
dryness, and swelling of the papillae; serous secretion, rapidly 
becoming purulent ; small-celled infiltration of the epithelial struc- 
ture ; and some shedding of epithelial cells. If the disease last for 
some time, the deeper layers may become infiltrated, with loss of 
epithelium in places. In the beginning the changes may be con- 
fined to isolated spots. When caused by chemical irritants, such as 



DISEASES OF THE VULVA AND VAGINA, 



195 



strong solutions of iodine, a sort of vesication may occur, with 
exfoliation of large layers of epithelial tissue looking like false 
membrane. As the vaginal epithelium has the power of resisting 
the invasion of the gonococcus, gonorrheal vaginitis is the result of 
a mixed infection. 

In the severer cases, and particularly acute attacks engrafted 
upon chronic inflammation, in the hyperemia dependent upon preg- 
nancy, or other disturbing influences, the papillae undergo the same 
changes, but to a greater degree. The epithelium is exfoliated, and 
the enlarged papillae resemble a mass of granulations, giving rise to 
the name Granular Vaginitis. \ 



Fig. 127. 




Granular Vaginitis. 



In children and in old people, in whom the papillae are smaller 
and the epithelial layer thinner, the inflammation is usually found 
more in patches, the secretion scanty, the surface smoother, and 
often ecchymotic in spots. The epithelium is shed in places and 
the surfaces may be glued together. We then have Adhesive 
Vaginitis. 



Fig. 128. 




Adhesive Vaginitis. 



196 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



Emphysematous Vaginitis is an inflammation of the vagina 
attended with development of gas in small spaces and canals of the 
connective tissue and lymphatics at the upper end of the vagina, 
and usually in pregnant women. They project like little bladders 
on a raised hyperemic base, and collapse when punctured. Desqua- 
mation or ulceration may result. 



Fig. 129. 




Emphysematous Vaginitis. 

In Vesicular Vaginitis round vesicles form over the inflamed 
areas, and after bursting leave sharply-defined raw surfaces about 
the size of a split pea. 

Follicular Vaginitis, consisting in enlarged inflamed follicles 
about the vaginal fornices, where the membranes may be supposed 
to possess more the character of a mucous membrane than lower 
down, is said to occur occasionally during pregnancy and in middle 
and advanced age. Whether the little nodules observed are really 
enlarged follicles or not is still a matter of controversy. 

The older authors describe vaginitis as an inflammation of a 
mucous membrane, but the tendency now is to look upon it as 
more of the nature of a dermatitis, and thus some confusion as 
to nomenclature still exists. 

Symptoms. — In acute vaginitis the patient complains of a burn- 
ing pain in the vagina, usually a frequent desire to urinate, with 
dysuria, and more or less itching and burning pain about the 
vaginal entrance. There is also a feeling of heaviness about the 
pelvis, backache, and a very slight rise of temperature, A general 
feeling of malaise, a loss of appetite, and perhaps nausea, are some- 
times noticed ; sometimes irritability and indications of hysteria, 
and sometimes no general symptoms whatever. 

In the beginning there is a dryness of the parts, followed in a 



DISEASES OF THE VULVA AND VAGINA. 197 

few hours by a sero-piirulent discharge which tends to produce irri- 
tation externally. 

In chronic cases the symptoms are similar, although less pro- 
nounced, and may be absent altogether. 

Diagnosis. — Upon inspection the vagina is found to be swollen 
and deeply reddened, either throughout or in spots, and presents 
the characteristics described in the paragraph upon the pathology. 
The discharge is white, pale green, or yellowish, and abundant, and 
may be thick and slimy in character from admixture with cervical 
mucus. 

Prognosis. — When promptly treated, the prognosis is decidedly 
favorable. When neglected, the consequences, particularly in the 
septic forms, are often serious. It may become chronic, result in 
ulceration, adhesion, cicatricial contraction, or spread to the uterus, 
Fallopian tubes, ovaries, and peritoneum. 

Treatment. — The indications in the treatment of acute vaginitis 
are to avoid and to relieve irritation, and to secure cleanliness. 
The patient should be kept quiet (not necessarily in bed), somewhat 
restricted as to diet, and the stools kept soluble. Walking, sexual 
intercourse, and scratching the parts must be interdicted. 

The great source of irritation is found in the infective matter 
and the character of the discharges. These must be removed as 
well as possible from contact with the vaginal membrane. Constant 
irrigation of the vagina would accomplish this, and, but for the 
trouble and irritation attending its use, would be recommended 
with the expectation of curing the case (if treated in the begin- 
ning) in from two to six days. A copious vaginal douche, con- 
tinued for fifteen minutes, of a hot (i of 1 per cent.) saline solution 
or saturated solution of boracic acid, used in the recumbent position 
every two hours by day and every four hours by night, answers 
equally well, except that it may take longer to accomplish the 
desired result. It should be kept up in this w^ay for a week, and 
used four times a day and once at night for another week or until 
a cure is obtained. If the disease have lasted several days, as 
is often the case, before the treatment is commenced, a mild anti- 
septic or astringent douche may be required during the second and 
third week, such as 1 : 3000 solution of mercuric bichloride, a i of 
of 1 per cent, solution of acetate of lead, sulphate of zinc, or car- 
bolic acid. If the disease shows a tendency to become chronic, the 
strength of the solution may be doubled. In no instance should 



198 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

an astringent vaginal injection be used during the first few days of 
acute vaginitis. 

In cases in which so much douching is not well tolerated or is 
not available, the disease can be rapidly cured by the dry pack, 
used as follows : The vagina is first thoroughly douched out with 
the saline solution. Then the patient is put on the left side, a 
Sims speculum is introduced, and the cervix and vagina thoroughly 
swabbed out with a 1 : 2000 solution of mercuric bichloride and 
thoroughly dried with absorbent cotton. If the vagina be exces- 
sively tender, the bichloride solution need not be used, for it is 
necessary to avoid irritation. After drying out the parts the 
vagina should be loosely packed with sterilized plain or borated 
absorbent cotton, packing first the fornices and then the lower 
parts of the canal as the speculum is withdrawn. A dry absorbent 
dressing should be worn over the vulva and changed by the patient 
every two hours. The douching, disinfection, and packing should 
be repeated morning, noon, and night for the first two or three 
days, and after that twice a day for a week. As a precaution 
against return, a 1 per cent, carbolic-acid douche, or, if not 
well borne, the saline or boracic-acid solution, should be used every 
eight hours for a week or two longer. Attention should be given 
to septic urethral or cervical discharges, or the vagina may con- 
stantly become reinfected. 

Kectal suppositories or medication should be carefully avoided, 
as there is danger of infecting the bowel. In case such infection 
occurs, the rectum should be thoroughly washed out every three 
or four hours with the saline solution by means of a return tube. 
Forcible dilatation of the sphincter ani adds to the efiiciency 
of the treatment. The bowels should be moved once or twice 
daily by salines. 

Morphia with atropia, or chloral may be required in nervous 
patients to secure quiet and sleep at night. 

In chronic cases attention should be given to general conditions 
that might favor the local irritation, to external sources of irrita- 
tion, and especially to conditions that favor pelvic congestion, 
whether they lie within the body or in the habits and external 
surroundings. 

Large antiseptic douches, such as 1 : 2000 bichloride of mercury, 
should be used two or three times daily. Every four to six days 
the vaginal fornices may be swabbed out with a 2 per cent, solution 



DISEASES OF THE VULVA AND VAGINA. 199 

of nitrate of silver in the tincture of iron, and a loose vaginal tam- 
pon covered with vaseline left for twenty- four hours. Treatment 
by dry powders, such as equal parts of subnitrate of bismuth and 
prepared chalk, or of tannin and iodoform, kept in place by a cotton 
tampon, is used by some gynecologists. The powder should be 
renewed every day, having the tampon removed and the old pow- 
der thoroughly douched out just before the treatment. 

In the senile and vesicular forms mild antiseptic douches are 
indicated, supplemented by strips of lint soaked in a 5 per cent, 
carbolized oil or smeared with 5 per cent, carbolized oxide-of-zinc 
ointment, or, in sensitive cases, of cold cream or almond oil kept in 
the vagina. 

In giving douches for vaginitis it should be remembered that 
there are many folds and irregularities that hide and retain the 
secretions ; hence it is well to have the patient lie on the back 
with the hips elevated on the bed-pan, so that the vagina will be 
well filled. The bag of the fountain syringe should be consider- 
ably higher than the patient and the nozzle introduced well up 
toward the fornices. Tampons are best placed with the patient in 
the knee-chest position. 

Cystic vaginitis is best treated by puncture of the small cysts 
about the cervix, and the application, after their evacuation, of the 
tincture of iodine. A vaginal douche of a 1 : 2000 solution of 
mercuric bichloride should be used twice daily. 

In hospital practice, where there is always some one in attend- 
ance to give the douche, a bulb is preferable to a fountain syringe 
because the water can be pumped into the vagina with more force, 
and thus dislodges the secretions better. 

Neoplasms of the Vagina. 

Vaginal Cysts. — Vaginal cysts, excluding cystic vaginitis, are 
sacs of fluid contained in or just beneath the vaginal wall, varying 
from the size of a marble to an egg, although if not interfered with 
they may attain a much larger size. The fluid is usually thin and 
transparent, but occasionally slightly viscid and turbid. The cyst- 
wall is intimately connected with the surrounding tissues and usually 
lined with cylindrical epithelium. Pavement epithelium has been 
found in a few cases. The cysts may be situated in any part of 
the vagina and occasionally assume a polypoid character. 

Recent investigators attribute them to an embryonal origin. 



200 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



Accumulations of fluid in the partly-obliterated canals of Gaert- 
ner or ducts of Miiller, particularly the former, are supposed to 
produce them. 

They give rise to but few symptoms until they have attained 
sufficient size to press upon the vaginal entrance and cause a sense 



Fig. 130. 




Cyst of the Posterior Vaginal Wall. 

of discomfort and pressure, and perhaps some leucorrhea. They 
may then assume the appearance of a prolapse of the vaginal wall. 
Where a prolapse is in process of formation, a vaginal cyst may go 
far toward determining the result. 

The DIAGNOSIS is easy. When on the lateral vaginal walls, 
they are felt as hard elastic bodies that yield a thin transparent 
fluid upon aspiration. When situated upon the anterior wall, they 
may be recognized by putting a sound in the bladder and a finger 
in the vagina ; or when on the posterior vaginal wall, by the fore 
finger in the rectum and the thumb in the vagina. 

The TEEATMENT consists in excising a part or the whole of the 
cyst- wall. When situated low down, they can easily be dissected 
out of their bed and the wound sewed up with buried catgut sutures. 
When situated higher up and complete excision is impossible, a 
portion of the cyst-wall should be excised, the remains painted 
with tincture of iodine, and packed with iodoform gauze. 

Fibroid Tumors of the Vagina. — Fibrous and myomatous tumors 



DISEASES OF THE VULVA AND VAGINA, 201 

seldom grow from the vaginal walls. True fibro-myomas, however, 
are not infrequently met with. They may be situated in the vagi- 
nal walls the same as vaginal cysts and of the same size, or they 
may become pediculated. They present the same symptoms and 
feel much the same as the cysts, except that they are not as elastic, 
and they do not yield fluid to the aspirating needle. As they grow 
larger the surface may ulcerate, or as a polypoid fibroid is extruded 
from the vulva the capsule may undergo necrosis. Sometimes they 
are quite oedematous and soft. 

The polypoid growths may be simply cut oW and the pedicle 
I'gatured if necessary. The intramural tumors should be enu- 
cleated and the bed sewed up, as after excision of a vaginal cyst» 

Papillary Excrescences. 

Small papillary growths of non-malignant character are some- 
times found on the inflamed vaginal mucous membrane. They 
consist of a proliferation of connective tissue and epithelium. They 
are insensitive, but give rise to an irritating and somewhat offensive 
discharge. Sometimes they bleed quite profusely. 

They should be obliterated by a strong astringent or caustic appli- 
cation and the vaginitis treated by the ordinary remedies. 



INFLAMMATORY DISEASES OF THE UTERUS. 



Anatomy. — It is essential to a proper understanding of the 
various forms of endometritis that a short description of the anat- 
omy of the endometrium be given. The internal os fairly well 
divides the lining membrane of the uterus into two very different 
and dissimilar portions. The corporeal endometrium begins here, 
lines the whole inside of the body of the organ, and extends, mod- 
ified, into the openings of the Fallopian tubes. Its characteristic 
features are these : it is firmly attached to the muscular tissue by 
a stroma of connective tissue. From this latter radiates a fibrillar 
tissue in no certain arrangement, which is found in lymphoid struc- 



FiG. 131. 




Fibre of the Endometrium, showing different grades of corpuscular development. 



tures only. Attached to these delicate bands and between them are 
innumerable lymphoid cells of various sizes. This arrangement 
persists throughout the membrane up to the epithelial covering. 
This covering is of cylindrical cells, ciliated, but one laver in thick- 

202 



INFLAMMATORY DISEASES OF THE UTERUS, 



203 



ness, and lines the utricular glands. These latter are merely deep 
depressions, with perhaps branches dipping down into the lymphoid 
tissue. (See Fig. 85.) There are also lymph-spaces in the mucosa. 
They extend from the mucosa to tlie spaces between the bundles of 
muscular fibres. The lymph-vessels are most abundant in the ex- 
ternal muscular layer, are connected with the lymph-vessels of the 
mucosa and serosa, and run into large canals at the side of the uterus. 
The serosa has lymph-vessels only, arranged in a network, and, while 
less numerous than those in the subserous tissue, they are much 
larger. Thus the lymph passes from the mucous membrane lymph- 
spaces into the spaces and vessels of the muscularis, surrounds all 
the muscular bundles here, up to the serous coat, and then passes 
into large tubes in the broad ligaments. The uterine mucosa is, 
then, either an open lymphatic gland or a lymphatic surface inter- 
sected by blood-vessels, the lymphatics being not mere vessels, but 
spaces between the bundles of connective tissue. 



Fig. 132. 




Lymphatics of the Uterus: 1, lymphatics from the body and fundus of the uterus ; 2, ovary ; 3, vagina 
4 Fallopian tube ; 5, lymphatics from the cervix ; 6, lymphatic vessels from the cervix going to the 
iliac ganglia ; 7, lymphatic vessels from the body and fundus going to the lumbar ganglia ; 8, anasto- 
mosis of cervical and uterine vessels; 9, small lymphatic vessel in the round ligament going to the 
inguinal glands ; 10, 11, lymphatic vessels of the tubes which empty into the large lymphatic vessels 
from the body of the uterus ; 12, ovarian ligament. 

The mucous membrane of the cervix is dense, hard, free from 
lymphoid elements, and is a true mucous membrane. It rests on a 



204 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



The glands are numerous 



submucous structure of connective tissue, 
and of tiie compound racemose type. The membrane is thrown 
into interlacing folds {arbor vitce), and is covered by a columnar 
epithelium, in places ciliated, but on its vaginal aspect the covering 



Fig. 133. 




Normal Mucous Membrane of the Cervix. The mucous membrane of the Cervix is very firm and presents 
a number of branching folds (arbor ^atse). The interglandular tissue, which has, in the body of the 
organ, the nature of granulation tissue, is here of a connective-tissue type, the fusiform and stellate 
cells predominating. There is not the same clear limit between membrane and muscular coat ; one 
can follow the glands deeply inward, among the connective-tissue bands, which separate the mus- 
cular bundles. Consequently the mucous membrane in section has a partly reticulated, partly fascic- 
ulated appearance. The cervical membrane possesses, moreover, many vascular papillae. Cylindrical 
ciliated epithelium invests the glands in the adult, and in the child extends to the external os. In 
the adult, especially after pregnancy, the flat vaginal epithelium rises higher and lies more or less 
within the cervix. Between the superficial cylindrical epithelium and the glands, cup-shaped and 
colloid cells are here and there present. The vessels pass into the mucous membrane perpendicularly 
and have very thick walls, dividing progressively into a capillary plexus, which is less developed 
than in the body. Sometimes the capillaries lie very superficially under the epithelium, reuniting to 
form veins, which at once leave the mucous membrane. The glands and ovula Nabothi are sur- 
rounded by the vessels. 

is of squamous epithelium. The lymphatics of the cervix are not 
so numerous as in the body, and do not enter the broad ligaments, 
but, joined by those from the upper part of the vagina, pass back- 
ward to the iliac glands and those in the obturator space. 

Physiology. — A certain force, the origin of which is not known, 
operating through the vaso-motor nervous system, causes periodically 
an increased flow of blood to the uterus, producing thereby a wonder- 
ful series of changes. These consist of a great increase in the num- 
ber of lymphoid elements in the mucosa, exfoliation of the epithe- 
lium covering the membrane and part of that lining the follicles, 
and rupture of the capillaries. Thus is produced the menstrual 
flow. The circulatory pressure subsides, the capillaries heal, a new 
epithelial covering to the surface and glands is produced, and the ex- 
cess of lymphoid cells is absorbed, this repair and waste occurring once 
in the month. There is no exfoliation of the mucosa, and the above 
changes are limited to the corporeal endometrium. The follicles of 



INFLAMMATORY DISEASES OF THE UTERUS. 



205 



the uterus secrete a more or less milky fluid, somewhat viscid, alka- 
line in reaction, and free from pathogenic germs. Normally this 
secretion from the utricular follicles is so slight as not to be notice- 
able. The uterine secretion contains germs of no kind. It is simi- 
lar in this respect to the gastric secretions. The glands of the 
cervix secrete in abundance a tenacious mucus. Germs are con- 
stantly present in the cervix. The cervix is solely for the pur- 
pose of acting as a sphincter to the uterine muscle, and its mem- 
brane is not involved in the menstrual act. Its secretion is clear, 
like white of egg, very tenacious, and abundant. 

Fig. 134. 




Transverse Section through the Upper Part of the Cervix, showing the Entire Mucoiis Membrane. The 
Central Cavity is the cervical canal : 6, 6, Internal Surface of mucous membrane, presenting small 
folds, superficial glandular depressions, and large incisions of the arbor vitae (d) ; g, g, deep glands ; 
a, a, ovules of Naboth ; m, m, muscular tissue of the uterine wall. 

The endometrium is solely for the purpose of forming the placenta. 

Menstruation is merely that, periodically, the uterus gets into 
a condition more propitious for conception than at other times. The 
menstrual blood escapes, as it does in apes, because the uterine 
mucosa is of such dense character, compared to that of other ani- 
mals, that its lymph-streams are not of sufiicient size to carry off 
all the products of the monthly engorgement. 

The escape of an ovule, exfoliation of the epithelium from the 
surface of the endometrium, engorgement of the endometrium with 



206 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

blood, and multiplication of lymphoid cells, are the factors which 
are, invariably, necessary on the part of the woman, that conception 
may take place. 

The lymphoid cells produce the decidual cells, and, by them, repro- 
duction of the mucosa is brought about, after its removal ; lymphoid 
cells also form the new epithelial layer. 

In the endometrium of the child there are few corpuscles, abun- 
dant fibrillar tissue, and the follicles are mere dimples. In the 

Fig. 135. 




Menstruating Endometrium of a Womau aged 20, showing Utricular Follicles denuded of Epithe- 
lium, with one still containing an Epithelial Cast. 

fully-developed woman the corpuscles crowd the tissue and are of 
all sizes. The whole membrane appears to be made of them. The 
glands branch, dip deep into the lymphoid tissue, and are lined 
with cylindrical ciliated epithelium. In old women there is 
nothing left save fibrillar tissue, a few corpuscles, and wasted 
utricular follicles. Between these extremes may be found all 
gradations, and in the same uterus at different times the arrange- 
ment and condition of vessels, epithelium, glands, and corpuscles 
so vary as to constitute essentially a different organ, under the influ- 
ence of the controlling factors, menstruation and gestation. Inflam- 
matory processes, then, imposed upon these widely dissimilar states, 
furnish a great variety of pathological appearances, and will cul- 
minate in some one of a great variety of microscopic changes. There- 



INFLAMMATORY DISEASES OF THE UTERUS. 



207 



fore, we must not expect every inflamed uterine mucosa examined 
to exhibit characteristics identical with some known standard. As 



Fig. 136. 




Endometrium of a Woman aged 60, showing Exhaustion of the Whole Structure. 

the conditions under which inflammation may occur are many, so 
must be the pathological changes. 

Endometritis. 

Inflammation of the endometrium should be considered from the 
standpoint of its etiology, and, inasmuch as the treatment is largely 
governed by the causation, classification according to the latter is 
eminently proper. Therefore endometritis may be described as 
simple, septic, or specific. Descriptions of endometritis based upon 
the symptomatology and classed by authors as hemorrhagic, hyper- 
plastic, etc., are confusing, and are merely different phases of the 
same pathological condition. 

Simple Endometritis. — This is usually symptomatic and never 
acute. The membrane may be hypertrophied or atrophied. In 
the first condition the follicles are many-branched and tortuous 
with thickened epithelium, which is still deposited in one regular 
layer. The vessels are enlarged and increased in number; the 
lymph-spaces are increased in size, and the muscular walls thick- 
ened. The epithelium is easily brushed off, causing bleeding ; the 
spaces about the follicles are filled with lymphoid cells, and the 



208 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



F^^- ^^"^v whole general aspect is one of 

increased growth and excess of 
nutrient fluid. Should there be 
an increase of connective tissue 
and accompanying glandular hy- 
pertrophy, the condition known as. 
"fungoid'' is produced. Here the 
fungoid elevations are cystic and 
lined by cuboidal epithelium. 
After abortions portions of de- 
cidua may remain adherent ; this 
is not a true product of inflam- 
mation, but rather the growth of 
a tissue which has partly retro- 
graded. Hypertrophic simple en- 
dometritis is usually found asso- 
ciated with those lesions which 
are pre-eminently characterized 
by a general enlargement of the 
uterus, as in retroposition, fibroid, 
subinvolution, etc. ; or, glandular 
hypertrophy may occur, produc- 
ing mucus polypi. 

These polypi hang by a longer 
or shorter pedicle, and may even 
project from the cervix, although 
attached above the os internum. 
When they touch the os internum 
the cervix will be dilated and patu- 
lous, or even gaping open. 

If the membrane be atrophied, 
the follicles with their epithelial 
linings are decreased in size, the 
lymphoid tissue is not so rich in 
cells, and the whole membrane 
is below the normal in thickness. 
There is an abrupt demarcation 
between the mucosa and the mus- 
cularis, and no intermingling of these structures. There may, in 
very chronic cases, be so great an increase in the connective tissue 




Benign Adenomatous Degeneration or Hyper- 
trophic Glandular Endometritis. 



INFLAMMATORY DISEASES OF THE UTERUS. 



209 



as to destroy every vestige of gland-tissues, or, constricting cer- 
tain glands, cysts may be formed. This form of interstitial change 
is rare except in old women, but is very similar to the alterations pro- 
duced by zinc-chloride and nitric-acid applications. Simple ante- 
flexion and non-development are the chief causative factors in 
the condition of atrophic endometritis. The blood escaping at 
the menses readily coagulates, owing to the scarcity of lymphoid 
elements ; the epithelium, instead of melting off gradually, sepa- 
rates in shreds or even as a whole cast. No micro-organisms are 
found, save, occasionally, secondary tubercle bacilli. Altered circu- 

FiG. 138. 




Glandular Endometritis ; Polypoid Form. 

lation by position or flexure, and consequently perverted local 
nerve-function, are the chief elements entering into the causation 
of these two very common conditions of the endometrium. They 
can scarcely be considered as truly inflammatory, but may at any 
time become actively so. 

This glandular endometritis when forming distinct elevations or 
fungosities constitutes the condition known as " benign adenoma." 
The only adenoma from the uterine mucosa is adeno-carcinoma, or, 
in plain words, cancer. 

In all forms of inflammation of the endometrium the epithelial 
cells are deposited in but one regular row of single cells — never 
in layers. Beginning cancer may readily be distinguished by 

14 



210 



AN A3IEBICAN TEXT-BOOK OF GYNECOLOGY. 



three things : the glands are not only increased in number, but are 
many times larger than the normal ; the epithelium lies in layers ; 
and the epithelial elements invade the subjacent tissues later on. 



Fig. 139. 




Pc7^p 



Diffuse Papillary Adenoma of the Body of the Uterus with Polypi. 



Therefore, when examining curette scrapings, unless they present 
but one thickness of epithelium arranged about the glands as one 
regular layer, the case must be looked upon with suspicion. 

Symptoms. — When the membrane is hyperto^ophied, in addition 
to the symptoms of the causative lesion, we have certain definite ones 
due to the hypertrophy alone. The menses are increased in amount, 
sometimes painful ; the flow dark, clotted, or clear. There may also 
be intermenstrual bleedings. Bimanual examination reveals the 
gross lesion causing the condition. The sound readily produces 
bleeding, and frequently develops at the internal os a point of 
exquisite sensitiveness. The depth of the organ is increased. 



INFLAMMATORY DISEASES OF THE UTERUS. 



211 



The cervical flow of mucus is tenacious and usually milky in 
character, owing to the excessive admixture of epithelium and 
lymphoid cells. There is no erosion of the cervix, and the cer- 
vical membrane is not often coincidently inflamed. Menstruation 
is followed by a more or less persistent leucorrhea. 

When the hypertrophy has gone on to the production of fun- 
gosities, increased menses, intermenstrual bleedings, and a profuse 
leucorrhea, often purulent, are the characteristic symptoms. The 
same is true when portions of decidual tissue have been retained 
and grown to the endometrium, thus forming buds and excrescences. 

With a less degree of hypertrophy the chyle-like fluid (leucor- 

FiG. 140. 




Section of a Glandular Uterine Polypus : a, a, superficial nodules covered with cylindrical epithelium : 
h, mouth of glands opening into a depression between ; g, deeper portions of the same glands ; v. v, 
blood-vessel. 

rhea) is non- irritating and devoid of germ-life. It is composed of 
increased secretion, fat-globules, lymphoid cells, and epithelium, and 
has no odor. 

With polypi the amount of hemorrhage produced is often so 
great as to suggest fibroid; and even a very small polypus may 
give rise to alarming floodings. The uterus always treats these 
growths as foreign bodies, the cervix remaining patulous and soft, 
and the uterine muscle making ineflectual spasmodic, attempts at 
expulsion of the growth, especially at the menses. Besides the 



212 



AN AMEBIC AN TEXT- BO OK OF GYNECOLOGY, 



intermenstrual bleedings, there may be a more or less continuous 
discharge of dark, coffee-colored fluid suggestive of malignant dis- 
ease. There can be no question that these polypoid granules, 
although in the beginning perfectly innocent, will, if allowed to 
remain for years, take on the characteristics of malignancy, in that 
their epithelial elements will invade the surrounding tissues. 
Always there is more or less of a purulent leucorrhea, due to 

Fig. 141. 





Interstitial Endometritis with complete Atrophy of the Glands ; A, cystic formation, last trace of the- 
glands ; B, all vestige of gland-tissue disappeared. 

colonies of cocci becoming established upon the generally abraded 
surface of the polypi. The rest of the endometrium may remain 
free from the pathogenic germs. 

Often it is impossible, without intra-uterine touch, to distinguish 
polypoid endometritis from corporal cancer. The character of the 
growth determined by the microscope will enable us to differentiate 
absolutely. 

Where the membrane is atrophied the dysmenorrhea is often 
excessive. This pain precedes the flow by a few hours, is located 
just behind the symphysis, and is intermittent, alternating with the 
escape of clots. The flow is scanty or watery. There is also a 
slight leucorrhea. In both conditions there are digestive disturb- 



INFLAMMATORY DISEASES OF THE UTERUS, 21S 

ances and reflex nervous phenomena entirely disproportionate to 
the changes in the endometrium. Backache opposite the last lum- 
bar vertebra, " bearing-down,^^ and a sense of weight more often 
accompany the hypertrophic form. Sterility results from the atro- 
phic variety more frequently, and is directly dependent upon the 
altered state of the endometrium. 

Teeatment. — In no form of uterine disease is general treatment 
of so much benefit. It may even cure certain cases. Thus, a change 
of climate, the " rest-cure," and an out-door life, may determine such 
alterations in the general nutritive functions, as to relieve these 
patients of most symptoms. It is in these cases of chronic simple 
endometritis that the various springs and watering-places are of 
benefit, the general surroundings and change in mode of life accom- 
plishing the improvement, by acting through the general absorptive 
system. The small quantity of arsenic and iron in the waters has 
but little effect. The dysmenorrhea and excessive flow are lessened 
by cannabis indica, gelsemium and hydrastis. When the mucosa 
is much hypertrophied, producing fungosities or polypi, with hemor- 
rhages, the proper treatment is always to remove the entire endo- 
metrium, and, if possible, correct the lesion upon which the endo- 
metritis depends. This should be done surgically, and not by the use 
of powerful chemical agents. If the gynecic surgeon will keep 
clearly before him the fact, that there is but a little tissue between the 
endometrium and peritoneum, rich in connecting blood-vessels and 
lymph-streams, if he will view endometritis from the peritoneal 
rather than the vaginal aspect, he can make no error in choosing the 
proper method of treatment. Although the inside of the uterus, in 
these cases, is free from micro-organisms, yet they are in the vagina. 
To treat patients by zinc chloride, carbolic acid, electricity or other 
escharotics, is to produce a more or less extensive slough, retained to 
become putrid, and is to create a surface deprived of that protecting 
epithelial covering which is the organ's sole defence against the 
inroads of pathogenic germs: and they do this in an unclean 
way, with no provision for drainage. The hypertrophied mem- 
brane should be removed with the sharp curette, as will be described. 
Possibly incision of the cervix, or even amputation, maybe neces- 
sary to get good drainage, all of which is merely preliminary to 
the dilatation, curettage, and gauze packing. Atrophic simple endo- 
metritis, and the hypertrophic variety when slight, can be relieved 
by removing the causative lesion and treating the endometrium by 



214 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

gauze packing. Drainage with stem pessaries, whether perforated or 
grooved, is a delusion. They do not drain, but are mischievous 
affairs, hard to keep open and clean ; and, as AVylie, the great expo- 
nent of drainage by stems, remarks, " the endometritis is apt to come 
back." The application of mild antiseptics and astringents to the 
endometrium thus inflamed is a perfectly proper procedure, but 
care must be exercised that with the application pyogenic cocci are 
not introduced. If the change in the endometrium does not war- 
rant operative procedure, the vagina and cervix should be thor- 
oughly cleansed, a narrow strip of iodoformized gauze introduced 
into the uterus, and the vagina packed lightly with the same material. 
In two days this is changed and a larger piece of gauze introduced, 
the canal being then more patulous. When this gradual dilatation 
has gone so far as to ensure good drainage through an open canal, 
there is hypertrophy of the uterus, and intra-uterine astringents are 
used before introducing the gauze ; iodine is the preferable drug for 
this purpose. It is not only astringent, but germicidal, and is, 
moreover, not deep in its effects ; its action is limited to the super- 
ficial structures only, and therefore produces no slough. The 
patient is not kept in bed, but confined to her room. The treat- 
ment is not painful after the first few sittings, and the endometritis 
is relieved in two weeks, though it will recur if the causative dis- 
ease be not removed. The treatment should be begun a week after 
menstruation. Instead of iodine, pure ichthyol as an application 
may be used with good results. 

The treatment of endometritis by chloride-of-zinc pencils is still 
practised by a number of physicians in America and abroad. This 
procedure causes the exfoliation of the endometrium. It does this 
by destroying the membrane, which is cast off by suppuration, and 
a simple hypertrophic endometritis is converted into a septic pro- 
cess by its use ; at the same time, a septic metritis is set up, and 
salpingitis and peritonitis often follow the treatment. The pain it 
produces is agonizing. Nothing could be more unscientific. Even 
though curettage were a dangerous procedure, and the curette often 
thrust through the uterus, it could not produce the destructive lesions 
which zinc does. The same objections attach to the use of nitric acid. 
Not only is the treatment itself most painful, and prone to produce 
serious lesions of the adnexa, but it also leaves the uterus in a crippled 
condition. The new endometrium produced is atrophic, the uterus 
the seat of connective tissue changes, and menstruation incomplete, 



INFLAMMATORY DISEASES OF THE UTEBUS. 215 

attended by great pain due to tension, and hysterical manifestations. 
Even Munde, the chief advocate of the chloride-of-zinc treatment, 
admits its dangers ; it is certain that those dangers are not to be 
avoided by any effort on the physician's part, but are inevitably 
inherent in the method. 

Before making an application to the uterus, the entire field of 
operation should be cleansed by a solution of lysol, 1 J per cent., or of 
creolin, 2 per cent., scrubbing the vagina and cervix carefully with 
cotton pledgets held by forceps. An applicator is then wrapped 
with cotton and the cervical canal wiped with either of these two 
solutions or a carbolic-acid solution, 5 per cent., care being taken not 
to invade the inside of the uterus. If a probe is to be used, it 
should be heated in an alcohol flame to sterilize it. The direction 
of the cervical canal having been determined by the probe, a very 
fine fillet of iodoform gauze, 20 per cent., is laid over the applica- 
tor, which has been curved to the shape of the canal, and is pushed 
up to the fundus of the uterus. A stout silver probe, or Simpson's 
sound which has had its bulb cut off, makes the best applicator 
for this purpose. The uterus should always be gently drawn down 
and steadied by means of a tenaculum, to straighten its canal. The 
ordinary tenaciila prick the membrane, cause pain, and are followed 
by the loss of a drop of blood. To avoid this, a very coarse double 
tenaculum, made like the American bullet forceps, the points being 
so dull that they do not penetrate the mucous membrane, may be 
used. A wad of iodoform gauze, the size of a silver dollar or 
larger, is then carefully adjusted over the cervix, and another 
of borated cotton is placed over this, to retain it in place. Treated 
this way, no odor of iodoform is noticeable about the patient, and 
the field of operation is kept perfectly aseptic from one treatment 
to the other. It is useless to do this if the patients are allowed to 
have intercourse or douches, or if the vagina is in any way in- 
vaded. After the treatment they may go about their rooms, and 
should be perfectly comfortable. It is not to be forgotten that the 
condition which causes this change in the endometrium must be 
cured. Polypi, fungosities, and retained decidual tufts are to be 
removed by the curette ; they are not amenable to palliative treat- 
ment. Iodine is not of much benefit in the atrophic form, but 
ichthyol is. These latter cases often prove intractable. If they be 
subjected to the gauze packing for the three weeks preceding the 
period, and the last dressing removed three days before the menses 



216 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

come on, it will be found that the flow is increased in quantity, 
is more nearly normal in character, and the pain less severe. The 
same treatment may be repeated the next, and if necessary the suc- 
ceeding months. After the cervix has become so dilated that it 
will receive a filament of gauze half the size of a lead pencil, one 
may rest content with the result. The uterus is not to be packed, 
but the gauze is gently introduced to the fundus. The cervix has 
the property of dilating around any foreign substance in its canal, 
and gauze packing of this size is amply sufficient to ensure good 
drainage. The results of the treatment are very satisfactory. 

Septic Endometkitis. 

Septic endometritis is an infectious inflammation of the endo- 
metrium, usually caused by staphylococci, occasionally by strep- 
tococci. It may occur at any time of life and in any condition 
of the uterus, but it is most frequently seen during the menstrual 
life of the woman, being favored by that function and pregnancy. 
It may be chronic, but is most often seen as an acute affection. 
The pathology and symptoms will be modified by the condition 
of the uterus at the time of the attack. Infection of the post- 
partum uterus belongs more properly to the province of the 
obstetrician. 

Acute Septic Endometritis. — Acute septic endometritis is caused, 
in the greater number of cases, by infection after abortion ; many 
cases, however, are caused by foul manipulations of the uterus, and 
operations upon that organ. Inasmuch as pyogenic germs are 
constant in the vagina, auto-infection is possible under certain con- 
ditions, but it must be exceedingly rare. Any factor which induces 
exfoliation of the epithelium, such as menstruation, abortion, rough 
treatment, sudden congestion, exposure to cold, and the introduction 
of infected instruments into the uterus, puts that organ into a con- 
dition propitious to the development of infection. 

Pathology. — In the acute form the uterus is enlarged and 
engorged with blood. The mucosa is swollen, of a deep color, and 
the number of vessels actually increased. In spots it may be 
necrotic or the whole membrane may slough. The epithelium 
covering the membrane and lining the follicles is exfoliated to a 
greater or less extent, and the vessels, present on the surface, 
rupture, giving rise to capillary bleedings. Pus-cells cover the sur- 
face and fill the follicles ; in aggravated cases they are found also in 



INFLAMMATORY DISEASES OF THE UTEBUS. 



217 



the lymphatics and lymphoid tissue. The muscularis is of a very 
deep color, softened and much thickened, even in a few hours. Its 
lymphatics are gorged with cocci, in advanced cases, and its blood- 
vessels with blood. True septic metritis is present. Staphylococci 
are everywhere in the membrane, sometimes even penetrating the 
muscular walls. Rarely are streptococci found except in puerperal 
cases. 

Fig. 142. 




i.._.-^ 



Puerperal Endometrium removed by Curettement on the Seventh Day : a, Necrotic layer of the decidua ; 
h, zone of reaction ; c. Sections of the glands ; d, Sections of the blood-vessels ; e, Remains of the 
glandular epithelium. 

In chronic septic endometritis the same lesions occur, only to a 
less degree. There is a general reproduction of epithelium, and the 
more acute symptom, necrosis, is absent. Pus is produced in 
quantity in the glands and on the surface of the membrane. The 
cocci may have penetrated the muscular wall, and there formed a 
pus -focus even amounting to abscess. In doing this they follow 
the lymph-streams. Complications are most likely to accompany 
these conditions, and the changes due to pelvic lymphangitis, 
ovaritis, salpingitis, and peritonitis may be found. 

Those cocci which are found present and arranged in groups are 
staphylococci, the germs always found in septic endometritis ; those 
in chains are streptococci, which cause many cases of, and are found 
in, puerperal infection. 

Symptoms. — The acute stage is often ushered in by a chill, espe- 
cially after abortion. This is followed by severe uterine colic, which 
soon becomes a continuous pain. The temperature rises to a varia- 



218 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



ble degree, with rapid pulse. In a few hours the uterus discharges 
a greenish pus or one tinged with blood. The uterine pain is 
severe, and the patient keeps the bed. Examination reveals the 
uterus enlarged and very sensitive. The parts have increased heat. 
From the cervix projects a rope of muco-pus, possibly bloody. If 
the disease has lasted a few days, the cervix is eroded, and may 



Fig.. 143. 















^^^ 

^^t 
♦** 



h .iy 





















./->' 



* i 



Cocci from an Empj'ema ; prepared by Gram's Method. 

even be covered by a true diphtheritic membrane, the result of 
infection by streptococci. Some of the complications which follow 
this condition may be present and add to the symptoms. The acute 
symptoms may subside in a few days, provided the very common 
complications of peritonitis and salpingitis do not overshadow the 
symptoms of the endometritis. Thus the acute form may gradually 
become chronic, with few symptoms other than a little pain, " bear- 
ing-down," and a purulent leucorrhea. It is not always easy to dis- 



FiG. 144. 




Syringe for the removal of Cervical Secretion. 

crim.inate a chronic simple endometritis from a chronic septic one, 
but in the latter there is the invariable clinical feature of purulent 
discharge from the uterus, which is not present in the former. This 
pus does not always appear in the cervical mucus, but it can always 
be obtained with the suction syringe, and it usually follows the 



INFLAMMATORY DISEASES OF THE UTERUS, 219 

withdrawal of the sound. The symptoms of gonorrheal endo- 
metritis are very similar to those of the septic variety. In some 
cases the microscope alone will differentiate the two forms, which 
are frequently blended. No investigations have yet been made, 
as to the appearance of peptones in the urine in acute septic endo- 
metritis, but an examination would probably disclose their presence. 
Whenever pus escapes from the uterus, it is an absolute indication 
that pyogenic cocci are in that organ, and clinically the case is 
either in a septic or a specific state. 

Treatment. — The radical treatment is the best : thorough and 
complete removal of the septic focus, irrigation, and gauze packing 
is recommended, as these uterine inflammations must be considered 
in the light of their complications. Prompt interference may cut 
short the disease, and save the patient those gross changes in the 
tubes and peritoneum which so often result from a neglected septic 
endometritis. If destructive disease of the adnexa has already 
taken place, the curettage is none the less indicated. The more 
acute the symptoms, the greater the indication for the operation. 
Some cases of chronic septic endometritis without complications 
may be cured without the use of the curette, by the introduction 
of drains of iodoformized gauze, but this method must be pursued 
with the strictest attention to asepsis. The presence of a purulent 
uterine discharge positively contraindicates the use of applications 
and stem pessaries, unless the applications be accompanied by the 
use of the gauze drain. The only treatment, then, applicable to 
acute and chronic septic endometritis, when complicated by disease 
of the adnexa or peritoneum, is curettage. Whether the septic 
condition follows, treatment, operation, or abortion, whether it 
accompanies cancer, polypi, fibroids, or other neoplasms, yet must 
the septic uterus be cleaned out before any other treatment is 
instituted. If infection follows plastic work on the cervix, the 
sutures should be removed, the uterus curetted and packed. There 
are so many important minor details in the after-treatment of sep- 
tic endometritis that they require separate attention. 

When a uterus not enlarged is curetted for uncomplicated chronic 
inflammation, the gauze need not be removed for from four to eight 
days, and but one renewal is necessary. In renewing the press- 
ings, infection is easier than at their first application, for the rea- 
son that the uterus is now divested of its protecting lining. 
Care should therefore be taken not to reinfect the case. The 



220 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

second dressing may remain from four to seven days and then be 
removed. All interference with the vagina, in the shape of douch- 
ing, coition, and examination, should be prohibited for the remain- 
der of the month, and the patient must take to her bed on the 
appearance of menstruation. When the curetting has been done 
on an enlarged uterus acutely infected, as after abortion — say, at 
the third month — the dressing should first be changed on the third 
day ; sooner if the temperature rises or other acute symptoms 
appear. Subsequent dressings are made whenever the one be- 
comes saturated. After the uterus has become entirely clean, with 
non -purulent discharges, the use of iodine is indicated, to overcome 
the existing subinvolution. This latter condition occasionally pro- 
duces a simple hypertrophy of the mucosa, which will, at the sub- 
sequent one or two periods, give rise to menorrhagia. The larger 
the uterus the longer the treatment must be continued. After the 
first dressing the packing is loosely placed. The treatment is not 
painful. The uterus is always to be steadied by using the blunt 
bullet forceps, hooked into the anterior lip. After abortion at the 
third month, irrigation is also employed at the dressings. The 
larger the cavity the more elaborate the treatment. In other 
words, these infected uteri are treated exactly as other discharging 
septic cavities, only here drainage is more difficult to obtain. 

Gonorrheal Endometritis. — Of all forms of virulent endometri- 
tis, this is the most common. 

Pathology. — Acute gonorrheal endometritis presents the same 
gross lesions as the septic form. Microscopically, we find that the 
gonococci penetrate but little below the surface, and are chiefly 
found in and under the epithelium. They follow the lymph- 
streams to a less extent than the staphylococci. Again, there is 
pus produced in true gonorrheal endometritis, but sloughing never 
follows this form of infection. No case has yet been reported of 
fatal primary gonorrheal endometritis. Systemic infection is not 
as severe as in the septic form. The great complication is salpin- 
gitis, by direct tissue extension from the uterus to the tubes. 
Chronic gonorrheal endometritis is very frequent, resulting from 
a subsidence of the acute form. Here the gonococci occupy the 
follicles and lie beneath the epithelium. They do not penetrate 
deeply into the mucosa, and do not extend along the lymph-spaces. 
Therefore they do not cause peritonitis and systemic infection except 
by extension through the tubes. Each menstrual period sees a 



INFLAMMATORY DISEASES OF THE UTERUS. 



221 



greater or less increase in the invasion, and recurrent attacks of 
tubal disease are frequent. 

Symptoms. — Possibly some one or all the symptoms of gonor- 
rhoea! vaginitis or vulvitis are present, but they may all be absent, 
and the first and sole indication of infection may be the sudden onset 
of a virulent endometritis. There may be occasional rigors, fever, 
and great pain in the uterus. The temperature does not at first 
range high, and the initiative chill is not prominent. The pain in 
the uterus is of long continuance, with exacerbations. In a few 
hours the discharge of muco-pus appears, oftentimes tinged with 
blood. If there be no extension of the infection, the symptoms 
of profuse discharge, slight fever, and pain gradually subside in 
ten days or less, leaving behind merely the symptoms of chronic 
purulent endometritis. 

The local symptoms are indentical with those of septic endome- 
tritis, but gonococci are found in the discharges. 

Fig. 145. 




Gonococci (two days after infection). 

Although these appear irregularly grouped in the pus-cells, yet 
on close inspection they may almost always be seen to be arranged 
in pairs (diplococci), the opposite surfaces of each pair being 
flattened like two Ds (CID) back to back. They may be in groups 
only, and not show this diplococcus arrangement. Their manner 
of staining will then prove their character. 

Treatment.— If seen early and before the advent of any com- 
plication, the uterus should be thoroughly irrigated with a satu- 
rated solution of boracic acid, or a bichloride-of-mercury solution, 
1 : 5000 ; after which a drain of iodoform gauze should be intro- 
duced, and the vagina filled with the same material. In twelve 



222 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

hours both dressings may be removed, the uterus again irrigated, 
and more gauze inserted. It is easier to subdue gonorrheal than 
septic endometritis. If the first attempts to control the disease fail 
we may be sure that the infection is a mixed one. If there be the 
complication of salpingitis or peritonitis, the operation of curettage 
is necessary. The uterus is not the natural habitat of the gono- 
cocci, asthe endometrium has a pronounced resistant power against 
them; their home is in the urethra and vulvo- vaginal glands; 
therefore they invade the uterus in but a small number of cases, 
otherwise infected. 

Curettage. 

Curettage of the Uterus. — Admitting that in most cases patho- 
genic germs exist in the vagina and the cervical canal, the right 
does not lie with the surgeon to suppose the endometrium exempt 
in any given case of inflammation. Therefore a method must be 
adopted which presumes they are present in all cases. The instru- 
ments necessary for performing a curettage are — a speculum, double 
tenaculum, intra-uterine catheter, blunt-pointed bistoury, uterine- 
packing forceps, heavy applicator, curettes, uterine dilator, fountain 
or bulb syringe, and an intra-uterine packer. The operation is best 
done with the patient in the lithotomy position, and with Kelly's 
pad placed under the hips. The lithotomy position is preferable 
to Sims's, as irrigation is easier and at any stage of the operation 
a bimanual examination may be made. The solution for irriga- 
tion is preferably a saturated solution of boracic acid, but bichloride 
of mercury 1 : 4000, or even boiled salt-solution (7 : 1000) except 
in septic and specific cases, will answer. For cleansing the vagina 
laundry soap and a 10 per cent, creolin solution, or a li per cent, 
lysol solution, with a long-handled brush (sterilized), will suffice. 

By pushing the brush in and out, turning it, scrubbing here, 
then there, the vagina may be rendered aseptic. While engaged 
in using the brush, irrigation into the vagina may also be made. 
Too much stress cannot be laid upon this cleansing, and it should 
be as thorough as possible, going over and over the field, time and 
again. The vaginal canal should be scrubbed in this way whenever 
an operation is performed upon or through it. In septic cases espe- 
cially must it be thorough. The instruments to be used must be 
boiled in a solution of washing soda (3 per cent) for fifteen minutes. 
The instrument pans should contain a 5 per cent, carbolic acid 



INFLAMMATORY DISEASES OF THE UTERUS. 



223 



solution. Gauze may be prepared in a few minutes by boiling, 
wringing dry, and impregnating with as much iodoform powder as 
it will take up. It is not easy to make, however, and many firms 
furnish a fairly reliable quality. Always before using commercial 
gauze, it should be soaked in bichloride-of-mercury solution 1 : 4000. 
The field of operation should be covered by sterilized towels and 
the operator and assistants prepared as for coeliotomy. Instead of 
sponges, swabs of borated cotton wet in bichloride-of-mercury solu- 
tion, are used. Any stiff dilator will answer the purpose, but those 



Fig. 146. 




Instruments in Position for Dilatation of tlie Cervix Uteri. 



with screws should be employed carefully, for the blades are apt to 
tear the tissues, as the screw renders it impossible to relieve the pres- 
sure until too late. Goodell's instrument is a proper one. The 
vulva having been shaved, the patient cleansed and in position, the 
speculum is introduced and held by the assistant on the patient's 



224 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



right. The anterior lip of the cervix is seized with the double 
tenaculum, pulled down as far as desired, and given in charge of 
the same assistant, whose left hand rests on the pubic bones. In 
this way the uterus is held immovable. By bimanual palpation the 
size and position of the uterus are determined. The cervix should 
be cautiously dilated bilaterally, the grip relaxed, the dilator turned 
a little, and dilatation made in the new position of the instrument; 
in this way, by alternately dilating around the entire circum- 
ference of the cervix, the canal will be readily and safely dilated to 
an inch or more, several authorities to the contrary notwith- 
standing. It must not be forgotten that we are working in unde- 
veloped unstriped muscular fibre, to overcome the force of which, 



Fig. 147. 




Instruments for Curettement of Uterus. 



too sudden pressure must not be used. Dilatation by graduated 
sounds is not advisable, inasmuch as the pressure is made against 
the hold of the tenaculum, and either insufficient dilatation is made 
or the tenaculum tears the tissues. Under any circumstances the 



INFLAMMATORY DISEASES OF THE UTERUS. 225 

traumatism induced is much greater than when the steel instrument 
is used as described. Besides, the dilatation obtained is not suf- 
ficient to destroy the action of the local sympathetics, upon which 
depends the uterine colic and the expulsion of the dressing, as ob- 
served and complained of by those who use the graduated sounds. 
After dilatation the uterus should be washed out by means of the 
catheter, or the small nozzle of the bulb syringe, followed by the use 
of the curette. As large an instrument as can be introduced should 
be used. Gently introducing the curette, it is withdrawn, its cutting 
face downward, and by reintroductions and withdrawals the whole 
organ is systematically scraped. The small size is then used, if the 
uterus be firm, and the openings of the tubes and lateral angles 
scraped. The instrument is then turned so as to curette the fundus 
by a sweep from side to side. The danger from curettage lies not 
in the proper use of the instrument, but in introducing it roughly 
and with force. The instrument should be held as is a pencil, and 
used with a delicate touch. Blunt curettes are useless for this work. 
If a surgeon must use such because of the supposed danger attaching 
to the sharper instrument, it is questionable whether he should do 

Fig. 148. 



N-'e^Lfz.vsoxA'^ 



Sharp Curette. 

the operation at all. Again, and this is important — the dull curette 
scrapes ofi* only the epithelial and softer external portions of the 
mucosa. Thus its use may be harmful ; for if a septic infection 
be local, and the epithelium of the rest of the organ has sufl&cient 
resistant power against the cocci, the procedure but removes this 
sole protection against a general infection without going sufiiciently 
deep to remove the cocci, and thus creates for the germs a new field 
for extension. So it is manifest that in septic cases, at least, the 

Fig. 149. 



C A,EJ(^TZ.«»~ 5.0 v\^ 



Uterine Applicator. 

fancied safety of the dull curette, apart from its inefficiency, is a 
delusion. The object of the operation is to remove the entire 
endometrium, so that the cytogenic embryonic uterus may produce 
a new one under propitious circumstan'ces. Following the curet- 

15 



226 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



tage, the uterus is to be thoroughly irrigated again. If the organ 
is much hypertrophied, the entire cavity should be swabbed out 



Fig. 150. 




Bulb Syringe. 



with tincture of iodine on an applicator, or the application made by 
means of the intra-uterine syringe. 



Fig. 151. 




Braun's Intra-uterine Syringe. 



Uterine Tamponade. — The field of work being covered by 
clean sterilized towels and the hands washed, the gauze is intro- 



Fig. 152. 




Instruments for applying the intra-uterine tampon. 

duced in one long strip. If the cervix be thoroughly well open, 
the gauze may be gotten in with the packing forceps. It is usually, 
however, impossible, on account of friction, to tampon the uterine 
cavity except through an intra-uterine speculum, in which case it 
is first necessary to dilate the cervix. The uterus should be packed 
as tightly as possible, and the end of the gauze left projecting from 



INFLAMMATORY DISEASES OF THE UTERUS. 227 

the cervical canal. A light dressing of gauze is then applied to 
the vagina. The patient should not be allowed to soil the dress- 
ings with urine if it can be avoided. After each urination or 

Fig. 153. 




Tamponing the Uterus with Iodoform Gauze by means of the lutra-uterine Packer. 

movement of the bowels, bichloride-of-mercury solution 1 : 4000 
must be poured over the vulva from a pitcher. 

When repair begins, the uterus being relieved of the septic 
process, the new leucocytes and plasma-cells are not forced to exer- 
cise their phagocytic property by battling with pathogenic germs, 
but the plasma-cells have a healthy pabulum, and devote their entire 
energy to the work of regeneration. It is not merely non-sup- 
purating repair ; it is histiological growth. 

Curettage in Acute Pelvic Inflammations. 

The question of the propriety of curetting the uterus in the 
presence of acute tubal and peritoneal manifestations may be dealt 
with here. If the article on the anatomy of the endometrium be 
consulted, and one reflects that pelvic peritonitis is very rare in 
men, he will be forced to believe that the pyogenic germs reach 
the woman's pelvis through the uterus. That granted, it will 
become apparent at once that the sequence of pathological changes 
must be either endometritis, salpingitis, and peritonitis ; or endo- 
metritis, metritis, pelvic lymphangitis, and peritonitis. The ques- 
tion then is proper : Does this causative endometritis cease the 



228 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

moment the pelvic complication arises ? Surely it does not. The 
peritonitis is not a disease per se, but merely an effort on the part 
of nature to check a disease. One of its first acts is to shut off the 
tubal inflammation from the peritoneum, by closing with adhesions 
the fimbriated opening of the Fallopian tube, thus cutting off further 
extension through that channel. But no such fortunate result can 
be expected where, as is occasionally the case, the extension is also 
through the lymphatics. So rapid is absorption in this direction, 
in some few cases, that the general peritoneum may appear normal, 
and yet evidences of the infection present themselves on the dia- 
phragmatic peritoneum, as the first point above the pelvic lesion. 
It is irrational, then, to consider these septic conditions in the light 
of their results only, ignoring the original source of the trouble, 
which still remains septic and continues to feed the fire. So long as 
the infectious focus remains, just so long will the peritoneum throw 
out lymph. When once the septic focus is removed, the lymph- 
effusion will cease, and the possibility of further extension from 
the original source is out of the question. The patient, relieved 
from the ptomaine-poisoning, ceases to vomit, the emunctories work 
properly, and the digestive functions are well performed. From 
a state of acute poisoning, the case has, by this removal of the 
causative disease, been converted into one having only the results 
of the infection, though these are grave. It is eminently proper, 
therefore, in theory, to curette the uterus before dealing with the 
sequelae, in all cases of acute or chronic septic endometritis with 
salpingitis or peritonitis. In practice this theory has been proven 
correct and the results positive. Too many successful operations 
in cases of both septic and gonorrheal origin, have been reported 
by Pryor and Krug, to admit of question as to the propriety of 
the method. Since they first drew attention to the subject, it has 
been adopted by many surgeons as the first operation, indicated in 
these cases of acute septic endometritis with tubal and peritonitic 
inflammations, before the complications are dealt with. If, as is 
at times the case, it be deemed necessary to deal first with the 
complications, the diseased endometrium should be subsequently 
treated, if the uterine symptoms persist. 

The other methods of treating these cases are by the " expectant " 
plan of opiates and poultices, or immediate coeliotomy — a procedure 
extremely irrational in view of what we now know of the pathog- 
eny of pelvic inflammations. In no other part of the body is the 



INFLAMMATORY DISEASES OF THE UTERUS. 229 

unsurgical rule applied, of removing the result of septic infection 
and ignoring the cause. Still more is the abdominal section con- 
tra-indicated, as under these conditions it is made at the worst pos- 
sible instant. Tubal abscess must ultimately be removed, and adhes- 
ions severed. But if the primary coeliotomy be made, it is in a 
mass of effused lymph, and distended and adherent guts ; it leaves 
behind a septic uterus to generate further mischief. 

When the curettage is properly performed the improvement in 
the local condition is marvellous. Irrespective of its effect upon 
the result and technique of a future coeliotomy, curettage is posi- 
tively indicated in every case of acute tubal and peritoneal disease, 
when there is even a suspicion that the infection originated in the 
endometrium ; that is, in the majority of cases. Some of the 
acute symptoms, as fever, arise not from the pus focus in the 
tube or ovary, for such is more or less isolated from the general 
absorptive system, but from the septic endometrium pouring into 
the lymph-streams an endless supply of septic material. It is not 
necessary, for the control of these acute symptoms, to evacuate the 
pelvic abscess per vaginam : they are more immediately subdued 
by a curettage. Furthermore, if by any possibility there is no 
tubal disease, the curettage will remove every trace of the infection ; 
in these tender women, positive and precise statements of the pelvic 
changes are often difficult, and masses of lymph-effusion are fre- 
quently interpreted as tubal abscess. The method is no longer new 
and experimental, but is the one accepted by many American 
gynecologists. Brought to a case of acute salpingitis and perito- 
nitis, the indications are, not for a brilliant removal of the adnexa, 
but rather to adopt that method which will preserve the woman 
from those gross changes in the peritoneum or adnexa, for which 
so many coeliotomies are done, and to save her, if possible from 
an abdominal section. So wonderful is the ability of the per- 
itoneum to absorb and repair, that it should in all acute cases 
be given an opportunity. In the light of its causation, of its 
pathology, even of its results, acute tubal and peritoneal inflam- 
mations of uterine origin, are to be treated by curettage and gauze 
packing alone as the primary operative procedure. One of three 
methods must be adopted with these cases : either poultices and hot 
douches, curettement and treatment of the uterus as any septic 
cavity, or a primary coeliotomy. The first is the method of the 
midwife, and merely allows the infection to work its will in the 



230 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



pelvis. The second is surgical in every sense of the word ; while 
to adopt the third in every case, stamps a man as blind to reason 
and to the work of other men, and as willing to 023en a fellow- 
being's abdomen rashly and unnecessarily. 

We know that septic endometritis has but a small percentage of 
mortality, but what frightful ravages it makes in the peritoneum 
and adnexa ! We know that many men apply the curette improp- 
erly, and that possibly women are oftentimes worse after it than 
they would be were they let alone. But should faulty technique 
and ignorance deter us from laying down the proper treatment? 
Therefore the rules — and golden ones they are too — may be enun- 
ciated : 1, treat all cases of endometritis in the light of its possible 
results ; 2, treat all cases of septic and specific endometritis, with 
complications, in the light of their causes. If a sloughing polypus 
causes acute peritonitis, shall it not be first removed ? If a slough- 
ing endometrium causes the same complication, shall not the uterus 
be cleansed ? 

Method of Eeproduction of the Endometrium. 

Kepair and reproduction, after removal of the endometrium, is ac- 
complished by means of the lymphoid cells and multiplication of the 
epithelium and plasma cells. If these are met by pathogenic germs 



Fig. 154. 



a — 




Vertical Section Three Months after Curettement ; a, a, epithelium ; 6, h, new-formed glands ; c, connective 
tissue ; d, muscular tissue of the uterine walls ; v, v, blood-vessels. 



in numbers, their whole effort is concentrated upon the conquest 
of the germs. Consequently the leucocytes die in large numbers 
and form pus, while the plasma-cells, deprived of their normal 



INFLAMMATORY DISEASES OF THE UTEBUS. 



231 



pabulum (leucocytes), are limited in the differentiated function of 
gland-formation, and result almost solely in the production of con- 
nective tissue. 

Hence it is that after an aseptic curettage the endometrium is 
reproduced in a normal condition in about two months. Con- 
versely, after the membrane has been removed by means which 
result in suppuration, the endometrium is reproduced but imper- 
fectly. 

Fig. 154 is taken from a uterus three months after curettage, 
and it will be noticed that in almost every particular it is a normal 
structure. It resembles the endometrium of a young girl soon 
after the menstrual function has become established. 

Fig. 155. 




Vertical Section of the Uterine Mucous Membrane Fifty-three Days after the Application of a Caustic: 
a, a, epithelium; 6, connective tissue; c, c, c, c, section of the glands which have undergone cystic 
degeneration ; d, d, tubular glands enormously dilated ; m, muscular tissue of the uterine wall. 



This specimen (Fig. 155) was removed from a woman to whose 
uterus chloride of zinc had been applied fifty-three days previously. 



232 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



It will be noticed that the condition here is one of atrophic endo- 
metritis of a pronounced degree, with marked interstitial hyper- 
trophy — exactly similar to chronic interstitial endometritis. The 
gland-follicles are caught in the new connective tissue and form 
cysts, while the surface of the membrane is covered by epithelium ; 
the glands are scarcely to be found. 

These plates prove very conclusively, the facts which have been 
amply substantiated by clinical experience. It is fair to assume 
that any caustic agent, which can penetrate as deeply as chloride 
of zinc, will have the same effects. Such agents are nitric acid, 
caustic soda, and very strong electrical currents. 

The manner in which reproduction of the mucosa ensues is well 
shown in the accompanying illustrations. 



Fig. 156. 



a 



c.__ 





& 









r Njj). 



(^^C5^i-^- 



>s@^ ^ 



^«3\^-v(X>. 






-^^-^-r^>^^ ■-- -^— 






^JJi 



Xb 



^^>^- 






,2> <=>^ " - ^ ^"C^^o 



ca 07:?r-^^^.?^ t-:% 



Perpendicular Section of the Uterine Mucous Membrane Thirteen Days after Curettement : a, h, 
epithelium, newly-formed ; c, newly-formed connective tissue. 

The new flat epithelial cells, developed from the lymphoid cells, 
gradually change to cuboidal, to cylindrical, and finally to ciliated. 
The subjacent tissue grows so rapidly and the epithelial cells mul- 

FiG. 157. 








Perpendicular Section of the Uterine Mucous Membrane Thirty-one Davs after Curettement: a, a, n, 
cylindrical epithelium ; 6, d, proliferating cells in the deeper part of the epithelium ; c, new-formed 



tiply so fast that the surface of the membrane is thrown into a 
wavy line, which, as the process continues, takes on the charac- 



INFLAMMATORY DISEASES OF THE UTERUS. 233 

teristics of a plane surface studded with innumerable crypts. Thus 
is the new, perfect endometrium evolved from the basement mem- 
brane, after curettage. 

The AFTER-TREATMENT of cascs of Curettage for acute tubal or 
peritoneal disease is as important as the operation. In all cases of 
curetting after conception, irrigation should be practised on chang- 
ing the dressing. The details of the treatment are governed entirely 
by the two great principles : cleanliness and drainage. It would be 
folly to reniove the primary packing from a large uterine cavity and 
not keep the cervix open ; this would merely result in a reinfec- 
tion, as curettage and irrigation do not remove every particle of 
sepsis : the cocci are in the lymphatics and often in the venous sin- 
uses. After curettage, the septic uterus must be treated as any other 
septic granulating cavity, with this distinction : packing should cease 
when the uterus is reduced in size and its secretions become free 
from pus-cells. Further treatment may be necessary if the organ 
remains enlarged. Curettage does not absolutely prevent those symp- 
toms which follow subinvolution, as hemorrhages. Therefore, a curet- 
tage done for infection in a puerperal uterus may, later on, have to 
be repeated for the hypertrophic membrane which gives rise to the 
bleeding, and which is caused by the enlargement of the uterus. 
Hence the judicious use of iodine is to be recommended in all cases 
of enlargement of the uterus. It is wise in cases of retroposition 
to tampon the vagina with gauze, so applying it that it will act 
somewhat as a pessary in supporting the fundus. As a final cau- 
tion the most scrupulous attention to every detail of aseptic work 
must be employed at each dressing, lest the case be reinfected. 
This point cannot be too strongly insisted upon. Opium should 
never be used, as it produces tympanites and vomiting. The bowels 
should be kept open. After curettage the menses are apt to occur 
a few days earlier than the usual date. All treatment should be 
suspended during this period, except where the uterus is septic. 
Menstruation has no effect upon the routine methods other than 
to require more frequent changing of the dressings. 

Electrical Treatment of Endometritis. 

The advocates of electricity in the treatment of endometritis 
have not, as yet, established any substantial principles, applicable 
equally well to all parts of the body. They do not tell us the 
effect of electricity upon the various cocci, or its influence upon 



234 AN A3fEBICAN TEXT-BOOK OF GYNECOLOGY. 

the living cell. Does it cause unstriped muscular fibre to con- 
tract or to become flaccid? What is its influence upon the 
white blood-corpuscles and plasma- cells ? Take its application in 
cases of simple endometritis. The application of even slight 
currents causes the epithelium to exfoliate. The negative pole 
with from 50 to 70 milliamperes for ten minutes, the strength some 
authorities advise, does more than cause exfoliation of the epithelium 
— it destroys tissue for a slight distance. In septic endometritis it 
is said that the current destroys the cocci. Staphylococci will sur- 
vive being dried upon a cover-glass for ten days, and are then 
destroyed by exposure, of not less than ten minutes, to boiling 
water. Will even 100 milliamperes do that? But granted that 
the currents used will destroy cocci, what effects have they other 
than this ? A very mild electrical current stops the ameboid move- 
ments and checks the processes of cell activity, while it lasts. Cur- 
rents of moderate intensity destroy the vitality of all protoplasm 
within reach of the currents. The interpretation of this is very 
simple. It means that currents much too light to prove germicidal, 
cause exfoliation of the protecting epithelium, destroy the property 
of diapedesis of the white blood-corpuscles, and destroy the karyo- 
kinetic property of the cells or their ability to multiply. These 
currents rob the locality to which they are applied of nature's sole 
defenses against pathogenic germs — epithelium, white blood-corpus- 
cles, multiplication of cells. 

By curettage, dead tissue and useless cells are removed. Useful 
living tissue is not destroyed, but the plasma-cells of the various 
tissues are given an environment propitious to their development 
and growth. Can electricity remove the entire septic endometrium 
in a few minutes, and in a month produce a new healthy one 
capable of forming a placenta and nourishing a fetus? The 
methods here laid down can, and have. Conception has taken 
place five days after a curettage for purulent endometritis. 

The great scientific truths upon which, deductively, the method 
by curettage with its positive results, has been produced, cannot 
be ignored for another, based upon empiricism, and unsuccessful 
empiricism at that. The established surgical rules which, the world 
over, are accepted for inflammations in other parts of the body, are 
applied to the treatment of endometritis ; and until gynecologists 
who practise the electrical treatment, can lay down for our guidance 
the positive indications to be filled, and reasons for their proposi- 



INFLAMMATORY DISEASES OF THE UTERUS. 235 

tions, indications which are scientific and facts which are not mere 
personal statements, the use of this measure cannot be recommended. 
Glittering generalizations will not sufiice. What they propose to 
accomplish within the hidden organs must have been successfully 
tried on those within view. If fibrous tissue may be removed within, 
so may it without. If suppuration may be checked within, ample 
opportunity presents for testing it without. If glandular hypertro- 
phy is corrected in the uterus, so may it be elsewhere. A few years 
back, when gynecology consisted merely of the dictum of one or 
two world-famed men, the electrical treatment might have become 
established. To-day, in the critical light of modern research and 
the generous distribution of knowledge, it exists, not because of true 
merit, but through the timidity of suffering womankind, who grasp 
at the hand offering relief " without an operation." 

Inflammatioist of the Cervix. 

The cervical mucous membrane, because of its anatomical cha- 
racteristics, is less often the seat of destructive inflammatory changes 
than the endometrium. Classification of changes in the cervix is 
usually made according to the clinical appearances. This is too 
confusing and elaborate. Every case of non- malignant cervical 
disease may be placed in one of the following classes : 

Septic and Gonorrheal Endocervicitis. 
Glandular Endocervicitis. 
Cervical Hypertrophy. 
Cicatricial Stenosis. 

Septic and Gonorrheal Endocervicitis. — Acute gonorrheal and 
septic processes here are not important, except in view of the 
possibility of extension to the endometrium. The cervical mucous 
membrane is dense, with few lymphatics, and drainage is so readily 
obtained, that pelvic lesions from cervicitis are rare if they ever 
occur. Acute infection of the cervix seldom remains local, but 
soon becomes general in the uterus. It is as a chronic inflamma- 
tion that we most often see cervical lesions existing alone. Its 
compound racemose glands do not readily shed their epithelium, 
and cocci rest for great lengths of time, attenuated and quiet, in their 
secretion. This fact being known, we are able to explain the 
development of latent gonorrheal endometritis and accept the pos- 
sibility of auto-infection. 



236 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



Glandular Endocervicitis. — This takes the form of enlargement 
of certain poitions of the normal folds. There is a projection or 
budding of the membrane, and as this increases the mouths of the 
glands become obliterated. The imprisoned glands continue to 
secrete, and the enlargement thus becomes pedunculated, forming 



Fig. 158. 




Mucous Polypi from the Interior of the Cervix and upon the Surface. 



a true polypus. Again, the epithelium of the cervix may be 
exfoliated as the result of a vicious discharge from above : or 
injuries from below, such as lacerations, may cause the production 
of granulations and erosions. But, contrary to the general opinion, 
instead of there being a loss of tissue with this condition, the eroded 
surface projects beyond the line of healthy membrane. As a result 
of long-continued irritation to its glands the connective tissue of 
the cervix may become moderately increased, thereby occluding the 
glandular canals, and in this way the entire cervix may become 
riddled with cysts, constituting cystic degeneration. Some of these 
cysts contain clear fluid and some pus. Interstitial hypertrophy of 
the cervix contributes the essential lesion in one form of anteflexion. 
Symptoms. — As all forms of cervicitis entail an enlargement of 
the cervix, there is the constant symptom of weight and heaviness in 
the pelvis. Acute septic and gonorrheal cervicitis is usually asso- 



INFLAMMATORY DISEASES OF THE UTEBUS. 



237 



ciated with some other symptoms of these infections, but, if occur- 
ring alone, the special symptoms are, that the cervix is engorged, 



Fig. 159. 




a, h, Simple Papillary Erosion ; c, Follicular, slightly enlarged, 

often eroded, and secreting its peculiar mucus, tinged with blood 
perhaps, but always very purulent. The cervical canal is often 

Fig. 160. 




Simple Follicular Cysts of the Cervix. 



gaping. Removal of this mucus is not followed by pus from above, 
showing the endometrium to be uninvaded. The several cocci are 
found by the microscope. The symptoms of chill and fever are 



238 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

wanting. Upon the subsidence of the more acute phenomena there 
will remain but the purulent discharge and some erosion. As has 
been said, acute septic and gonorrheal cervicitis tends to travel 
upward, and rarely will a case be seen before it has done so, owing 
to the absence of general symptoms due to the cervicitis alone. 
Glandular cervicitis, especially when it has gone on to the forma- 
tion of polypi, produces a purulent (often profuse) discharge, in 
addition to the subjective symptoms of bearing-down and weight. 
The most prominent reflex phenomena accompany cystic degener- 
ation and interstitial cervicitis. Headache is constant and the 
patient is very nervous. She is very emotional and prone to 
hysteria, the nervous symptoms being fairly well proportionate to 
the amount of interstitial change and follicular degeneration. The 
cysts project from the vaginal aspect of the cervix as rounded 
nodules, like blisters. If one be pricked, nothing escapes, but gen- 
tle pressure forces out a pearl of tenacious mucus. They occur not 
only on the surface, but in the deeper parts of the cervix also. In 
glandular cervicitis the canal is usually open, and by separating 
the lips the enlarged glands may be seen. 

Treatment. — Acute gonorrheal and septic endocervicitis are to 
be most vigorously treated. The plug of mucus must be removed, 
and the application of powerful antiseptics made, as pure carbolic 
acid, care being taken not to invade the inside of the uterus. The 
condition is very hard to check, and is extremely liable to become 
chronic ; but even then there is no better application than carbolic 
acid. Erosions due to purely local causes, as pessaries, can be 
readily cured by removing the cause and keeping the parts clean. 
Erosions are almost always dependent upon some form of glandular 
inflammation, either in the cervix or above, and are to be relieved 
by curing that cause. The association between cystic degeneration 
and beginning epithelioma is very close, while polypoid cervicitis 
is simple adenoma. Therefore the operative procedures directed 
to the cure of the latter need not be so radical as for the former. 
Inasmuch as polypoid cervicitis is seldom general, excision of the 
polypi is all that is necessary for isolated growths. This can be 
done under cocaine appplication. Should, however, it be associated 
with much interstitial hypertrophy, or the polypoid growths be 
general over the cervix, the excision of a 'portion from each lip 
will be of benefit in producing contraction. 

A general cystic degeneration is amenable to the wedge-shaped 



INFLAMMATORY DISEASES OF THE UTERUS, 239 

amputation of the cervix, an illustration and description of which 
will be found in the chapter on Malignancy. It is a good opera- 
tion, giving most excellent results, and is always to be preferred 
to Sims's operation, which necessitates a long-continued after-treat- 
ment for keeping the cervical canal patent. Many cases also, now 
subjected to Emmet's operation of trachelorrhaphy, were better 
operated upon by this method. 

Sims^s Operation. — This operation, at one time considered the 
best method by which to amputate the cervix, is now applied to 
removal of the cancerous cervix only, except by a few of the imme- 
diate followers of Dr. Sims. In its performance the cervix is 
grasped by a stout double tenacula. A blunt bistoury is entered 
into the cervical canal up to the internal os, and the cervix slit on 
one side only, to the extreme point of the proposed exsection. 
Without removing the knife it is carried all around the cervix, 
returning to the point of starting, thus removing a cone-shaped 
piece of tissue in the centre of which is the cervical canal. 

It will be seen that by this operation a large piece of tissue is 
removed, and there is no possibility of saving any mucous mem- 

FiG. 161. 




Cone of tissue removed by Sims' Amputation of the Cervix Uteri. 

brane for the cervical canal. The sutures of silver wire are passed 
in an antero-posterior direction, and are entirely buried. This is an 
important step, very difficult of execution when the exsection has 
been carried high up. The entire canal is closed except an opening 
in the centre for a stem pessary. The sutures are removed on 
the eighth day. Should the circular artery of the cervix be 
wounded — and its course is very variable — it is controlled by 
passing a needle, armed with a silver wire, beneath the vessel, 
twisting the wire and thus compressing it. This is merely tem- 
porary, and should be removed when the final sutures are applied, 
the latter being sufficient to control all bleeding. 



240 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Involution is very rapid after this operation, and is apt to be 
excessive. 

There being no canal left in the cervix, a stem pessary must 
be worn for months, and even years, to keep the new canal, with 
its cicatricial walls, open. These cases frequently return a few 
years after operation with the canal almost closed, and require 
incision and dilatation, for a long time. This is the great drawback 
to the operation, and one which precludes its use. The cone of 
tissue in tlie illustration is longer than it is usually necessary to 
remove. 

Cervical Hypertrophy. — Cervical hypertrophy may be so great 
as to simulate prolapsus, and, indeed, it may produce a certain 
amount of descent, but the fundus is always found higher than in 
prolapsus. The total length of the uterine canal is greater, the 
increase being chiefly in the cervix ; there is no rectocele, but a 
spurious cystocele accompanies the condition, as the urethra and 
base of the bladder follow the increased growth of the cervix. 
Still, the caution is necessary, that in amputating these hyper- 
trophied cervices great care be exercised lest the bladder be opened, 
as the hypertrophy may spring from near the os internum, in which 
case the vesical organ will be dragged down with it. The sound in 
the bladder, how^ever, will show the relations of that organ to the 
hypertrophy. The cervix may be so generally inflamed and, at the 
same time dilated, that the membrane will be rolled out, forming a 
true ectropion, and presenting the evidences of glandular hyper- 
trophy, even amounting to glandular polypi. Excision is here 
necessary by the method already indicated. 

Cicatricial Stenosis. — As a result of operations — especially of 
Sims's operation of exsection — inflammations, and application of 
caustics — rarely as a congenital lesion — we may have a cervical 
canal so contracted as to form a true stenosis, or an atresia ; the 
condition may even give rise to hematometra, and require treat- 
ment as for congenital atresia. It is amenable to the opera tioiji 
of bilateral incision. The after-treatment is long and tedious, and 
the patients are forced to remain under observation for a ^^eat 
length of time. This is necessary because the operation is usually 
done in a field of cicatrical tissue, which tissue possesses an inherent 
tendency to contract, repeated or continuous dilatation being neces- 
sary for its prevention. 

The exception to this treatment is where the stenosis is due to 



INFLAMMATORY DISEASES OF THE UTERUS. 241 

inflammatory changes. Here the bilateral incision is to be followed 
by gauze packing for three weeks, the packing being limited to the 
cervix alone. 

These shallow incisions, followed by dilatation, are covered over 
by a modified form of mucous membrane in a remarkably short time. 
Stem pessaries are not necessary, unless the tissue be newly-formed 
cicatricial tissue ; in other cases the cervix will remain dilated 
around even a very fine filament of gauze, and while the latter 
is in place the formation of the new membrane goes on speedily. 

In considering all these questions involved in the treatment of 
diseases of the uterus it must not be forgotten that the organ is em- 
bryonic and capable of reproducing its tissues to a certain extent, 
but reproduction does not take place from scar-tissue or in the 
presence of suppuration. 

Metritis. 

This condition is of very minor importance, because it is merely a 
name for certain changes in the muscular walls, secondary to more 
important conditions. An idiopathic metritis does not exist : it is 
always secondary to, and an extension of, the inflammation of the 
endometrium. Inflammation of the muscularis uteri follows all 
acute and many chronic infections of the mucosa. The treatment 
of the two conditions is identical, and has already been fully con- 
sidered under Endometritis. A low form of tissue change also 
accompanies the various neoplasms, flexions, and versions. These 
will be described in the proper places. 

SuBINVOLUTIOlSr. 

The condition known as subinvolution which follows labor is 
not, per se, a disease, but merely an association of conditions result- 
ing from a common cause. The uterus has not yet fully undergone 
those retrograde changes which normally follow labor. It is en- 
larged in all its diameters and the mucosa is thickened. The organ 
being heavy and its walls softened, it shows a tendency to sink low 
in the pelvis or take a retroposition. 

The intimate histological condition is one merely of fatty, en- 
larged, unstriped muscular fibres, enlarged vessels and lymph- 
spaces, and glandular hypertrophy of the mucosa. It can scarcely 
be termed strictly a pathological condition, rather is it an incomplete 
physiological one. When it has persisted for some time, fibrous 

16 



242 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

tissue hyperplasia does take place in the muscular walls, and the 
change in the mucosa becomes a permanent hypertrophy. 

Symptoms. — If the menses have returned, they are increased in 
amount, but are not painful. If the engorged organ is low down, 
retroverted or retroflexed, the symptoms present are of constant 
and severe backache, together with bearing- down pains. 

There may or may not be a complicating endometritis with 
pathological discharges or leucorrhea; most generally the cause 
of the interruption of the normal involution is a septic or specific 
endometritis. Under these circumstances all the symptoms of 
endometritis are present. 

Usually all patients complain of a sense of weight and heaviness 
in the pelvis. There are present the general symptoms of anorexia, 
costiveness, anemia, and general malaise. Women with subinvolu- 
tion are very subject to melancholia, which may even amount to a 
temporary insanity, not acute. Mania following labor and due to 
infection by streptococci is not to be confounded with this mild 
aberration of intellect. This condition is not a frequent one, and, 
when found, is generally in stout, plethoric women. 

Examination shows the enlarged, soft uterus, possibly low down 
or retroposed. It is not tender in uncomplicated cases, but is 
extremely so in the presence of an accompanying endometritis. 

Teeatment. — The general conditions predisposing to this mal- 
ady must, be met ; therefore strychnia and cinchona before meals, 
and wine and iron, are indicated. The combination of ergotin and 
quinia is exceedingly efficacious. 

Locally, intra-uterine applications of tincture of iodine, with the 
supporting and depleting tampon of ichthyol 5 or 10 per cent, in 
50 per cent, boroglyceride, twice a week, are all the requisites for 
effecting a cure, in the absence of any acute symptoms. Hot 
vaginal douching should be employed twice each day between treat- 
ments. If the hemorrhages are of serious moment, curettage not 
only removes that factor, but materially hastens the involution. 
General treatment is of great importance. 

If subinvolution be neglected, the organ is prone to take on 
almost any form of inflammatory change, and is especially liable to 
septic infection. The condition materially reduces the organ's 
resistant power against pathogenic germs. Many cases of grave 
pelvic lesions and uterine displacements may be traced to neglect 
in guarding against this condition after confinement or abortion. 



INFLAMMATORY DISEASES OF THE UTERUS. 



243 



Subinvolution is very frequently caused by a septic or specific infec- 
tion of the uterine cavity in the puerperal woman, resulting in an 




Subinvolution. 



endometritis. Such cases resolve themselves eventually into a true 
condition of metritis and endometritis, and are to be dealt with as 
such. 



Hyperinvolution. 

The condition known as hyper- or super-involution follows labor, 
and is due to causes unknown. The natural involution of the 
uterus following labor reduces the size of the organ slightly below 
its normal condition, but subsequently, within the course of a few 
weeks, this loss is regained. Occasionally involution does not cease 
at this point, but continues beyond the physiological condition, until 
the womb becomes, at times, even as small as an inch or an inch and 
a half in depth. The causes which change the physiological process 
into a pathological one are obscure, and can rarely be detected. 
Fortunately, the occurrence is rare, as the condition is extremely 
difficult to treat successfully, most commonly baffling all the efforts 
of the physician. 

Painful and scanty menstruation are common attendants, and are, 
in fact, the principal symptoms. The dysmenorrhea is of a severe 



244 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

and persistent type, usually appearing prior to the flow and lasting 
throughout its whole course, and is undoubtedly due to the atrophic 
condition of the endometrium. The ovaries may or may not be 
involved in the process : should they become involved, it would be 
one more causative factor added to the dysmenorrhea, and would 
exaggerate that condition. 

The physical examination, together with the history, renders the 
diagnosis clear. The uterus is found small and its walls of firm 
consistency, at times almost fibroidal in character. The depth of 
the uterine cavity is reduced from two and a half inches, the normal, 
to one or one and a half inches. 

The medical treatment of the disease is not productive of any 
assured success. It consists in rendering the patient's general health 
as nearly normal as possible, at the same time stimulating the uterine 
muscle. Probably electricity, both general and intra-uterine, gives 
as much promise of success as anything. Should the physician's 
efforts be attended with good results in accomplishing a return of 
the uterus to its normal size, the menstrual flow will become more 
natural in quantity and the dysmenorrhea will gradually disappear. 
Most often the treatment consists in simply controlling the pain. 
Efforts in this direction will be accomplished by much the same 
means as given in the chapter on Dysmenorrhea. As a rule, the 
patients will have to be content to bear their sufferings as best 
they may, with what amelioration drugs will give, until the change 
of life ends their period of probation. Should the pain become so 
great as to render life miserable, a resort may be had to ovariotomy 
with the view of bringing on an immediate menopause. The 
justification of this procedure must rest entirely with the individual 
case, the event being determined by the amount of suffering and 
the failure either to cure the condition or to relieve the symptoms. It 
is far. better to perform the operation of removal of the ovaries 
than to have continuous resort to opium, with all its attending 
dangers. The question of childbearing need hardly be considered, 
if for no other reason than that these women are rendered sterile by 
their condition. Pregnancy, if it could be brought about, would 
probably produce a cure, or rather it might be nearer the truth 
to say that this condition would be proof that a cure had been 
accomplished, as pregnancy is most improbable until there is a 
return to the normal condition of the endometrium. 



LACERATIONS OF THE SOFT PARTS. 



Laceration of the Cekvix Uteri. 

Laceration of the cervix is one of the commonest of all gyne- 
cological affections, and is the consequence of an attempted dilata- 
tion, whether by the head of the child in labor or by the uterine 
dilator in the hands of the gynecologist. 

The tear occurs in consequence of the refusal of the external 
OS uteri to dilate sufficiently to allow the head of the child to pass, 
the result being that there is a rupture, usually on both sides, which 
extends a variable distance up into the uterus and into the vault 
of the vagina, along the base of the broad ligaments. 

These ruptures are with remarkable uniformity bilateral ; occa- 
sionally unilateral or stellate. 

Deep fissures, unaccompanied by lateral tears, occupying the 
median line in front and behind, are almost without exception sus- 
ceptible of some other explanation. Posteriorly, for example, 
many cases observed are cases in which the operation of discis- 
sion or splitting of the cervix for the relief of dysmenorrhea, had 
been practised. Anteriorly, a median split is often significant of 
the surgeon's knife or scissors, used to incise the rigid os, or more 
often it arises from the use of the obstetric forceps. 

The immediate danger arising from these tears is the ready access 
afforded for the invasion of the pelvic connective tissue by septic 
germs. This is to be prevented by unusual care, during the con- 
finement and puerperium, in avoiding sepsis by cleansing out the 
vagina before labor where there is any purulent discharge, and by 
maintaining an aseptic condition during the confinement. 

If it is necessary to handle the cervix, this should be done with 
a sterilized rubber stall drawn over the finger. After the confine- 
ment, douches should not be given as a prophylactic, but become 
necessary when the existence of an infection has declared itself. 

It is not proper, in view of our light and methods of to-day, to 

245 



246 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

attempt the immediate repair of cervical tears. Where, however, 
there is a constant flow of arterial blood, trickling in a small stream 
from between the labia, and digital examination reveals the presence 
of cervical laceration, it will be found that the hemorrhage proceeds 
from the rupture of a cervical artery. In such a case an immediate 
operation must be undertaken. The patient should be brought to 
the edge of the bed, with the thighs flexed upon the abdomen — the 
dorsal position — and the posterior vaginal wall retracted with the 
aid of a Sims speculum. The blue, soft lips of the cervix, appear 
low down in the vagina ; they should be grasped by a pair of bullet 
forceps, drawn down to one side, and the tear from which the bleed- 
ing comes exposed. The operator then passes a needle deeply 
through the tissue, in such a way as to include the vessel and serve 
at the same time to approximate the torn lips. Two or three similar 
sutures below this uppermost one, each tied in the vagina, will serve 
to secure an accurate approximation of the lips throughout. The 
sutures must not be tied tightly, and no dressing should be applied 
in the vagina. Such an operation will be almost invariably success- 
ful. The sutures may be left in place for six or eight weeks if 
necessary. 

Where it is unnecessary, for the purpose of controlling hemor- 
rhage, and it is necessary only very rarely, to make an immediate 
repair, the patient is to be treated on the expectant plan. If na 
sepsis occur, to disorder the vaginal and uterine discharges, a spon- 
taneous closure of the laceration will take place. For the accom- 
plishment of this only ordinary care in the line of cleanliness is 
necessary. The majority of cervical lacerations are cured by nature. 

Some months or some years after a confinement one of three 
appearances will be observed in cases of laceration of the cervix : 
Firstly, the cervix presents a normal appearance with a slight or 

Fig. 163. Fig. 164. 





Side and Front Views of a Simple Bilateral Laceration, requiring no treatment. 

a marked notch on either side ; secondly, the cervix presents two 
well-defined lips, and is even torn down to the vaginal vault : the 
lips are soft, flaccid, and not thickened ; thirdly, the tear is not so 



LACERATIONS OF THE SOFT PARTS. 



24T 



evident on inspection as in the last variety, but the cervix appears 
thickened, and hardened, its angry red centre presents the appear- 



FiG. 165. 



Fig. 166. 





Front View of a Unilateral Laceration requir- 
ing no treatment. 



Side View of a Unilateral Laceration ; such a 
laceration maj^ cause abortion in the latter 
months of pregnancy. 



ance of an erosion, and distended glands are more or less 
abundant. Out of the cervical canal exudes a glairy or muco- 



FiG. 167. 



Fig. 168. 





Side view of a Bilateral Laceration, re- 
quiring treatment. The lips are 
everted, and the Nabotbian follicles 
stand out as prominent papillae. 



Front View of a Bilateral Laceration, show- 
ing eroded area and Nabotbian folli- 
cles. 



purulent secretion, which continually irritates the ulcerated part 
and prevents it from healing ; in fact it has in the beginning been 



Fig. 169. 



Fig. 170. 





Tenacula in place, showing aversion of lacerated 
cervix. 



Tenacula crossed, showing the method 
of approximating the lacerated lips, 
demonstrating the true condition. 



the origin of the ulceration. On catching the anterior and posterior 
margins of the cervical lips in two tenacula and attempting to draw 



248 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

them together, it is at once evident that there is a laceration with 
well-defined lips, which are deeply infiltrated. As the lips are 
drawn together the erosion in the centre is turned in and disappears, 
showing that it is a part of the mucous membrane of the cervical 
canal. In other words, the condition is that of a lacerated cervix 
with everted and eroded lips, that condition so frequently mistaken 
in the past for ulceration of the cervix. This third class of cases 
is the only one demanding treatment. 

It is an undoubted fact that the majority of cases of cancer of 
the cervix occur in women who have borne children and have a lacer- 
ated cervix. It is also undoubtedly true that cancer of the neck of 
the womb not infrequently occurs in nulliparous women. The only 
reason for the surgical treatment of the first two classes would be the 
fear that any ulceration of however small degree would have a de- 
termining influence on the development of cancer. This fear is, 
however, not so well supported by facts, as is generally supposed. 

Laceration of the cervix is frequently associated with subin- 
volution of the uterus and pelvic venous stasis. Leucorrhea, dys- 
menorrhea, aches and pains, a feeling of weight and bearing down or 
dragging referable to the pelvis, associated with a feeling of general 
weariness are the symptoms generally found in this condition. 

The best method of relieving these associated troubles is by re- 
pairing the cervix, in order to start involution of the uterus, which 
process commonly follows operative procedures on that organ. The 
steps of the treatment consist in the proper denudation of the lips 
and approximation of the denuded surfaces by sutures. Where 
infiltration is very marked the lips cannot accurately be brought 
together, and therefore preparatory treatment is required. 




Knife-bladed Tenaculum, used in scarifying Cervix. 

Preparatory Treatment. — This consists in measures calculated to 
deplete and diminish the size of the cervix. Douches of water, 
as hot as can be comfortably borne (110° F.), once or twice daily 
for from ten to twenty minutes, followed by a rest for an hour, 
are valuable adjuvants. The cervix must be exposed by the use 
of a Sims speculum, with the patient in the dorsal position. Deple- 
tion is then obtained with a fine knife, by opening as many dis- 



LACERATIONS OF THE SOFT PARTS. 



249 



tended follicles as can be seen. From four to eight drachms of 
blood should be drawn once or twice a week. By following each 
depletion with a pack of boro-glyceride on cotton, 50 per cent., left 
in for twenty-four hours, the cervix in from three to six weeks will 
be reduced in size and quite flaccid, and in a favorable condition for 
the plastic operation. 

Operation. — As a preliminary step it is absolutely necessary to 
make sure by a bimanual examination that there is no inflammatory 
disease of the pelvis involving the ovaries and Fallopian tubes. 
The patient is then placed in the dorsal position, with the buttocks 
on the perineal pad and the thighs held well flexed on the abdomen 
by the leg-holder. The cervix is exposed by retracting the poste- 
rior vaginal wall with a Sims speculum, and the anterior and poste- 
rior lips are caught by bullet forceps and drawn down to the 
vaginal orifice. A constant irrigation of the field of operation is 
kept up throughout the whole procedure. Drawing the cervix a 



Fig. 172. 



Fig. 173. 





Incision in the Angles of the Laceration. 



Method of Denudation. 



little to one side, an incision is made in the angles of the tear as 
deep as the denudation on the lips is to be carried. Scar-tissue is 
often encountered in the angles, and the incision must extend below 
this, into healthy tissue. 

From this incision the denudation is carried down, first on the 
posterior, then on the anterior lips, as shown in the diagram, by 



Fig. 174. 



BLADE 




Blade of Knife used in the Denudation. 



means of a sharp knife. Care must be exercised not to denude too 
much on the vaginal surface, and, on the other hand, to leave a 



250 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



small strip of undenuded mucosa in the centre on both lips, which 
will represent the future cervical canal. Both lips are similarly 
denuded. 

An effort is made in the denudation to go through cicatricial 
into the sound tissue everywhere, and to make such denudations 
as will, when approximated, secure a conical cervix projecting into 
the vault of the vagina, with a small external os. 

No fear need be entertained of wounding the circular artery. 
Any vessel which is divided during the operation will be controlled 
as soon as the sutures are introduced. 

The sutures are of silkworm -gut and fine silk ; the former at 
points of greatest tension, and the latter when necessary to secure 
accurate superficial union between the tense deep sutures. 

A small stout curved needle with its carrier is grasped in the 
needle-holder and a strand of silkworm-gut hooked into the loop. 
The operator, while the lips are drawn well apart by his assistants, 
introduces the needle just above the angle of the incision, on the 
vaginal mucosa, and with a sweep brings it out in the cervical canal 
high up. It then crosses the canal to a corresponding point, re-en- 



FiG. 175. 




Fig. 176. 




Silkworm-gut Sutures in place on one side, ready to be tied ; front and lateral views. 

ters the tissue, and reappears on the vaginal mucosa of the opposite 
lip, at a point opposite and corresponding to the point of entrance. 
A second suture is passed, in like manner, a little lower down on 
the lips, and often a third near the point. These sutures are left 
loose and clamped in a pair of artery forceps, while the sutures of 
the opposite side are introduced in like manner. 

There are two ways of securing sutures so as to hold the lips 
snugly together : they may be simply tied in a square knot, or they 



LACERATIONS OF THE SOFT PARTS, 251 

may be held fast in place by running a perforated lead shot down, 
and pushing it up on the suture until the lips are drawn closely 

Fig. 177. 




Silkworm-gut Sutures in Place, tied on the right and shotted on the left side ; intervening 

Approximation Sutures of fine silk. 

together, when the shot is squeezed and allowed to remain in place. 
When the vaginal outlet is operated upon at the same sitting, it will 
be easier to remove the cervical stitches if the shot is used. It is 
not necessary to observe such great care in removing all blood-clots 
from the angle of the wound before approximating, as has been 
generally supposed. 

The uppermost sutures are tied first, and then in succession the 
other ones. Any pouting between the sutures should be disposed 
of by introducing superficial sutures of fine silk between those of 
the silkworm-gut. 

The vagina is washed out after the operation, and a loose iodo- 
form gauze pack applied, which is left in place five or six days. 
The vulva is protected with sterilized cotton and a T- bandage. 

It is not necessary for the success of the operation, as far as 
securing good union is concerned, that the patient should remain 
in bed; it is, however, important in a certain class of run-down 
patients, for the sake of their general good condition and to make 
an impression on their nervous system, that they be kept in a 
recumbent position for two or three weeks. This combination of 
the rest cure with the operation is so important that it may well be 
doubted in many cases if the rest has not been the most important, 
if not the sole factor in the recovery. 

Catheterization need only be practised so long as the patient is 
unable to void urine. The bowels should be opened at least every 
other day, occasionally by mild purgative medicines, preferably by 
enemata of soap and water, or oil and water. 

The stitches should be removed in from three to six weeks ; when 
the vaginal outlet has been operated upon, they should be allowed 



252 



^iV^ AMERICAN TEXT-BOOK OF GYNECOLOGY, 



to remain two or three months undisturbed, to avoid dilating the 
outlet in their removal. They are best removed by placing the 
patient in the side position and retracting the posterior vaginal wall 
until one of the sutures is seen ; this is caught by a pair of forceps 
and drawn down until its loop is exposed, when it is cut and the 
suture drawn out. It is important after all have been removed to 
make a digital examination in order to verify the fact. Sexual 
relations should be forbidden for three months. 



Incomplete Ruptuke of the Recto- vaginal Septum. 

Recent. — Recent incomplete ruptures of the recto-vaginal septum 
appear as furrows in one or both vaginal sulci, extending down to 

Fig. 178. 




Virginal Vaginal outlet. 



the posterior commissure and outward, involving the skin perineum 
as far back as, but not including, the sphincter ani. These furrows 
are made by the child's head or shoulders in passing through an 
outlet either relatively too small or through one whose tissues are 



LACERATIONS OF THE SOFT PARTS. 253 

not sufl&ciently elastic, or, again, in entering the outlet in a faulty 
position, as in occipito-posterior positions. The forceps are a fre- 
quent factor in the production of these injuries. Shallow tears of 
this character may be neglected, and if the parts are not infected 
during the puerperium their natural apposition will generally be 
sufficient to ensure a partial primary union, provided injections 
have not been given during the convalescence and union prevented 
by the nozzle of the syringe entering into and separating the lips 
of the wound. Hemorrhages following these lacerations are not 
often serious, but are at times exceedingly annoying. 

Tears extending half an inch down into the tissue should be 
repaired at once ; that is, within the first twenty-four hours. It 
is a common but serious error to estimate the amount of injury 
by a superficial examination of the external parts. This is insuf- 
ficient, as the worst part of the tear lies concealed within the vagina 
and can only be disclosed under a good light and by separating the 
labia and walls of the lax vagina by two fingers. 

The process of suturing is simple, and is like that described in 
the operation for complete tear after the closure of the rectal lac- 
eration. As the natural tendency of the tissues is to lie in appo- 
sition, but few sutures are necessary to assist nature in the repair. 
It is well during their introduction to control the uterine discharges 
by a tampon of iodoform gauze, placed loosely against the cervix. 
Two or three silkworm-gut sutures are sufficient to close a long vagi- 
nal rent. The first one should be introduced . at the upper angle 
of the tear and passed well down to the bottom of the sulcus. On 
the skin surface two or three superficial or half-deep silk sutures 
will complete the approximation. A dry powder of boric acid or 
boric acid and iodoform (7 : 1), and a loose vulval pad of absorbent 
cotton, complete the dressing, which should be renewed frequently 
for the first few days. In eight or ten days all sutures may be 
removed, and, in the absence of sepsis, the union will be perfect, 
if the sutures have been well applied. 

Old Incomplete Teak. 

Relaxation of the Vaginal Outlet. — If a recent incomplete tear 
is neglected, there may be one of several results : a complete union, 
which is unfortunately rare, may occur throughout without inter- 
ference. A partial union may take place at the bottom of the tear 
while the upper part granulates and cicatrizes: the cicatricial 



254 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



contraction in such a union may be sufficient to compensate for 
the deficiency created by the tear. Finally, the result of such an 
injury is a permanent deficiency at the introitus, resulting in a 
relaxed outlet, from which the vaginal walls become more and more 
everted, forming cystocele and rectocele in the erect position, and 
from straining effi)rts, until finally in some cases the bladder, 
cervix, and uterus escape, a prolapse following as the result of the 
relaxation. 

A relaxed vaginal outlet is recognized by the flatness of the crease 
between the buttocks in front of the anus. Often, a series of con- 



FiG. 179. 




Relaxed Vaginal outlet as seen in the dorsal position. 

centric wrinkles surround the entrance of the vagina, which is 
dropped back nearer the anus. The commissure of the labia may 
be entirely uninjured, or it may be torn down to the sphincter, and 
replaced by a pit of scar-tissue. This latter fact in no way influ- 
ences the condition. 

On separating the labia on either side with the thumbs, the out- 
let presents an everted, gaping appearance, and on testing it with 
the fingers, its structures are found lax and incapable of resistance. 
The cervix is readily exposed by making a speculum of the fingers 
to push back the anterior and posterior vaginal walls, and the 
uterus is quite often found retroposed and in descensus. 



LACERATIONS OF THE SOFT PARTS. 



255 



The direction of the outlet in cases of relaxation is characteristic. 
Normally, it points downward and backward toward the end of the 



Fig. 180. 




i^AttiiiMSL 



Appearance of Relaxed Vaginal Outlet in Sims's Position. 

sacrum, while here its direction is toward the promontory or into 
the abdomen. 

The symptoms occasioned are numerous and in direct relation 
to the lesion. There is a feeling of pressure, of dropping out, of 
something protruding, and of discomfort on walking, the patient pre- 
ferring the sofa ; there is backache, and a dragging sensation, due 
to the increasing displacement of the uterus. Leucorrhea and all 
the symptoms of endometritis are apt to supervene. The bowels are 
constipated, as the expulsive efforts are wasted on the outlet, the 
sphincter ani muscle forming the greatest point of resistance. Nerv- 
ous symptoms, referred to the stomach and head, are but expressions 
of the general loss of tone. 

The treatment of this condition is by a resection of the outlet 
and both sulci in a similar manner to the Emmet operation. The 
denudation includes the posterior two-thirds of the outlet and ex- 
tends up each sulcus in the form of a triangle. It is unnecessary to 
extend this denudation on the outside, beyond the ring of the hymen 
or its broken remains, but it should be carried not less than an inch 
or an inch and a quarter up each sulcus. It is best to outline the 
area to be denuded with the point of a knife. Two points in the 



256 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



hymeneal ring are caught with curved tenacula on either side, be- 
tween a half and three-quarters of an inch from the urethra, these 
points being represented by the lower caruncles or remnants of the 
hymen. These points when drawn together will show the size of 



Fig. 181. 




Fig. 182, 




Looking down on the Floor of the Pelvis. 
Dotted lines indicate the area to be 
denuded. 



Area to be Denuded within the Vagina, out- 
lined with point of knife. 



the repaired outlet, due allowance being made for future relaxa- 
tion. The points, being widely separated, are now connected by two 
lines, made with the knife, the first U-shaped, from one tenaculum, 
down, around the posterior commissure of the labia, to the tenaculum 



Fig. 183. 




Area on Skin Surface to be denuded, outlined with point of knife. 

on the opposite side. The second is an inverted M lying entirely 
within the vagina, its middle point (1) being from three-quarters 
of an inch to an inch above the centre of the U, directlv on the 
crest of the rectocele. The side lines (2) (2) of the M lie on the 
lateral walls, parallel to and just below the anterior wall. The 
denudation is now rapidly made by catching up the tissues with 



LACERATIONS OF THE SOFT PARTS. 



25T 



dissecting forceps within the limits of the marking, and cutting off 
the tissue in long strips with scissors curved on the flat. Bleeding 
vessels rarely require tying, as the sutures, introduced immediately 
after the denudation, control all hemorrhage. 



Fig. 184. 




Drawing or Tension Suture, introduced and ready to be tied. 

Sutures are now introduced to bring the sulci together, and the 
first suture of silkworm-gut is placed about halfway down the right 
sulcus, entering and emerging on the vaginal mucosa close to the 
incision. At the bottom of the sulcus the suture appears at a point 



Fig. 185. 



Fig. 186. 





Drawing Suture tied, and Superficial 
Silk Sutures in place. 



Sutures tied on Right, and in place ready 
to be tied on Left side. 



lower down toward the outside than either the point of entrance or 
emergence. This suture is tied at once, and lifts up the lower part 
of the denudation, and also serves as a tractor, in bringing down the 
denuded area above, thus facilitating the introduction of the remain- 
ing sutures. 

The silkworm-gut suture is tied, and the approximation above is 
made perfect by three or four silk sutures, each of which must 
sweep well under the tissue, the last one being introduced at the 
angle to prevent hemorrhage from the vessels cut during the de- 



17 



258 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



nudation. On the opposite side silkworm-gut and silk sutures are 
placed in a similar manner. 

The wound-area is now reduced to a shallow pit, representing the 
lower end of the denudation in the sulci, on each side of the cen- 



FiG. 187. 




Sutures of Both Sides tied, aud the Crown Sutures in place. 

tral undenuded tit, and the more external part of the denudation 
already somewhat reduced in size. 

One or two gathering sutures now almost completely close this 
whole area. A silkworm-gut suture is introduced well below, trans- 
fixing the three points P, P, P (Fig. 187). By drawing these 



Fig. 188. 



Fig. 189. 





All Sutures tied, leaving a superficial area 
to be closed with fine Silk Sutures. 



Completed Operation. 



points together the wound is contracted to a superficial area, which 
can be readily approximated by a few superficial silk sutures. 

Laceration of the Perineum. 

Rupture of the Recto-vaginal Septum — In complete rupture of the 
perineum the septum between the genital and the alimentary canals 
is broken down for a variable distance, and both possess a common 
outlet. The tear extends from the posterior commissure of the labia 



LACERATIONS OF THE SOFT FABTS. 



259 



back through the perineum and the sphincter muscle into the rec- 
tum and for a variable distance up the rectum and vagina. This 
injury may vary from a superficial tear, barely involving the 



Fig. 190. 




Speculum introduced into the Vagina, showing the result of the operation. 

sphincter muscle, to a rupture extending one or more inches up the 
septum toward the cervix. The cause of this injury is parturition- 
dystochia at the vaginal outlet. 

One of the commonest causes of rupture of the recto-vaginal 
septum is rapid delivery of the child's head with forceps, thus 
bringing the head down upon an insufficiently relaxed outlet, 
and substituting a haf?ty delivery, accomplished during a few pains, 
for nature's slow equable dilatation attained after a great number 
of descents of the head, each time wedging the orifice a little farther 
open. The rupture in these cases begins at or within the posterior 
commissure, and extends rapidly back over the skin, perineum, and 
through the sphincter into the anus and up the septum. A head, 
unusually large, or one which has not been susceptible to moulding, 
or one persisting in the occipi to-posterior position, are all frequent 
occasions of this injury. 

The immediate dangers from sepsis are great in these cases, as 
in all difficult labors involving delay, becau=;e of extensive injury to 
the soft parts, more or less prolonged manipulation, and especially 
the subsequent constant contamination of the lacerated area by fecal 
discharges. 

Symptoms. — The common symptom is incontinence of fecal dis- 
charges and flatus. Where the rupture has merely extended through 



260 



AN AMEBICAN TEXT-BOOK OF GYNECOLOGY. 



the sphincter or but a short distance beyond, it is possible for the 
subsequent contraction of the scar-tissue, forming between the two 
ends, to so bind them together and give the sphincter muscle a point 
d'appui, that it will remain functionally active and no feces will 
escape, and sometimes the patient will control even the flatus. It 
is important to recognize this fact, as writers have positively asserted 



Fig. 191. 



Fig. 192. 





Normal Sphincter ; no break in the continu- 
ity of the circular fibres. 



Slight Solution of Continuity in the Sphincter 
filled in with connective tissue. No im- 
pairment of function. 



that with every tear of the sphincter its function is necessarily 
abrogated. We must be prepared, therefore, to meet lacerations of 
all degrees — shallow tears in which the sphincter's function is not 
apparently interfered with, those which are deeper, but in which 



Fig. 193. 



Fig. 194. 





Solution of Continuity imperfectly bridged 
over with connective tissue. Partial loss 
of function. 



Sphincter completely Ruptured. Divided, ends 
being widely separated. Complete loss of 
function. 



some control of feces is still retained, and still others in which there 
is a complete tear resulting in absolute incontinence, the flatus 
escaping and the patient soiling herself as soon as the desire for 
evacuation is felt. 

Treatment. — The only successful plan of treatment is reunion 
of the torn surfaces by suture. Such an expectant plan as binding 
the knees together and restraining the patient's movements after 
confinement, is to be rejected as worthless. In all these cases the 
immediate operation is called for within twenty-four hours after the 
labor. If performed aseptically, this operation will invariably be 
successful. 

The Immediate Operation. — If the patient has been greatly 
exhausted by the confinement, or if the physician is not prepared 



LACERATIONS OF THE SOFT PARTS. 261 

to perform the operation properly at that time, he may delay six, 
twelve, eighteen, or even twenty-four hours, before proceeding to 
unite the tear. The operation may be performed at once or after 
the patient has had a refreshing nap and some stimulation admin- 
istered. She is brought with her body lying transversely across 
the bed, the hips resting on the edge on a perineal pad, which 
drains into a bucket. If the bed have a spring or w^oven-wire 
mattress, and the centre sags so much as to prevent free drain- 
age, a board similar to the fracture-board used in hospitals should 
be inserted beneath the springs. It is not necessary to give an 
anesthetic unless the patient be so nervous as to be unable to 
control herself, as the traumatism which has been sufficient to 
cause the rupture has also produced partial anesthesia of the soft 
parts by pressure. A little moral suasion by the physician will 
often quiet a nervous woman sufficiently to secure her intelli- 
gent co-operation during the operation. The patient will some- 
times be able to hold her own legs flexed upon the abdomen by 
placing one hand under each knee, but it is always better to em- 
ploy some form of leg-holder, if at hand, as it relieves her of the 
tension. The leg-holder described in the chapter on Technique is 
the one which is best employed. It is placed beneath the neck at 
about the seventh cervical vertebra, one end passing over the 
shoulder and in front of the clavicle, the other behind the opposite 
shoulder and through the axillary space between the arm and side 
of thorax, after which both ends are clasped about the legs imme- 
diately above the popliteal spaces. A competent nurse or assistant 
with clean-washed hands stands by the operator ready to assist. 

The perineal and part of the supra-pubic hair is shaved off, and 
the vagina and external parts thoroughly cleansed, first with soap 
and water, and then with creoline solution (1 to 5 per cent.), or 
water sterilized by boiling. The "patient's legs and thighs are 
covered with a clean sheet, and a large piece of gauze, several folds 
thick, laid between the thighs over the buttocks and genitals to 
prevent contamination of the hands, instruments and ligatures from 
the patient's body during the operation. An incision through the 
gauze exposes the field for operation. The surgeon takes his seat 
in front of the patient, so that his shoulders are almost on a level 
with the vulva. His instruments are spread out in an orderly 
manner on a low table to his right, on a clean sterilized towel, or 
in a tray, covered with hot water. To his left is placed a basin of 



262 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

warm water for occasional cleansino; of his hands. An irrisrator 
containing two quarts of water at a temperature of about 110° F. 
hangs back of him three feet above the level of the bed. 

As the operator separates the labia with his left hand, the 
assistant directs the water on the parts which at the same time 
he gently sponges with pledgets of absorbent cotton. 

The extent of the tear into the rectum and up into the vagina 
must be carefully noted. Ragged tits and tissue which resembles 
large blood-clots must be trimmed off evenly with a pair of sharp 
scissors. 

The next step in the operation may properly be called the 
reduction of the compound and complicated laceration to a simple 
form of tear, by closing the rectal part of the rent. This is accom- 
plished by passing a number of interrupted silk sutures, beginning 
at the angle and extending down to and including the ends of the 
sphincter, each entering and emerging on the torn rectal mucous 
membrane and penetrating the septum one-eighth of an inch, which 
is deep enough to secure a firm hold. These sutures are then tied 
from above downward and the ends dropped into the rectum. 
There then remains but the edges of a deep perineal and vaginal 
tear to be approximated. This is repaired by deep sutures of silk- 
worm-gut, beginning in the vagina at the upper angle and passing 
down over the commissure on to the perineum and to the anus. 
Each suture extends to the bottom of the tear. They are tied 
from above down, as introduced. 

The lowermost external suture must enter and emerge well 
behind the divided ends of the sphincter, sweeping deeply around 
in the septum, and thus binding the sphincter firmly together, 
while the silk sutures already introduced secure accurate approx- 
imation. About four silkworm-gut sutures to the inch are sufficient. 
The patient should lie quietly in bed, but she need not be restrained 
from turning over gently or lying on her side. The bowels, instead 
of being locked, should be freely opened on the second day by 
a laxative, followed, if need be, by an enema given with extreme 
care. If an enema be ordered, careful directions as to the intro- 
duction of the nozzle of the syringe should be given to the nurse, 
as great injury may be done by its careless use. The nozzle should 
be gently introduced, passed back toward the sacrum, and then the 
contents of the syringe slowly injected. After the bowels are 
opened, a mild laxative should be administered every day or so, 



LACERATIONS OF THE SOFT PARTS. 263 

as the fecal discharge must be kept soft and thus straining at stool 
prevented. The vulval orifice and the perineum should be well 
sprinkled with iodoform and boric-acid powder (1 : 7), and pro- 
tected by a pad of sterilized absorbent cotton loosely applied and 
renewed three or four times daily. In eight or ten days the stitches 
should be removed by placing the patient in the same position 
as at the operation. The external sutures should be removed 
by drawing each to one side and cutting its loop, and then by 
pulling it toward the side on which the loop is cut. The inside 
stitches are exposed by elevating the anterior vaginal wall with 
a narrow Sims speculum or a retractor. Each stitch is caught in 
turn by a pair of forceps and lifted up, its loop cut, and the suture 
removed. 

The Intermediate Operation for Complete Tear, — During the 
process of granulation and formation of the cicatrix, the wound of 
a complete tear presents essentially different conditions to the 
operator from those found either immediately after the reception of 
the injury or later in the secondary period, when the scar- tissue has 
been fully formed. From the seventh to the fourteenth days the 
wound-area is covered with delicate friable granulations, and its 
margins are marked by pink lines, which contract until finally only 
a linear scar remains. The operation at this stage may be per- 
formed with ease, and is followed by good results. The patient is 
brought, as before, to the edge of the bed, and a pledget of cotton 
saturated with a 10 per cent, solution of cocaine hydrochlorate laid 
over the whole lacerated area. In ten minutes the operator may 
take his seat in front of the patient, and with his thumb in the rec- 
tum and his finger in the vagina draw one side of the torn area into 
view and thoroughly denude it down to healthy tissue by scraping 
off all the granulations with a sharp scalpel. The older the wound 
the greater will be the difl&culty of denuding its margins properly, 
and in some cases a sharp pair of scissors will be necessary to com- 
plete this part of the denudation. A freely-oozing surface with 
sharp margins is now exposed. The sutures are then passed as in 
the immediate operation. 

Secondary Operation for Complete Tear. — The secondary opera- 
tion is performed at any time after the formation and contraction of 
the scar-tissue is completed. It must be remembered, as it bears 
an essential relation to the denudation to be made, that the area of 
scar-tissue at this stage by no means represents the area of the 



264 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

original injury. The broad primitive wound -surface has contracted 
down into narrow lines more or less > < -shaped, the lower ex- 
tremities representing the position of the sphincter ends, the upper 
the commissure, and the transverse bar the lower margin of the rec- 
to-vaginal septum. The denudation must, therefore, be made to 
cover an area widely exaggerating the outlines of the scar-tissue. 

The sphincter area is generally characterized by a shallow pit, 
often marked by little dimples at either extremity of the septum, 
presenting a more or less sharp border, beneath which pout a 
few tits of the deep-red rectal mucosa. 

Before making the denudation the outlines of the area to be 
denuded must be mapped out with the point of a scalpel. This 
allows a rapid denudation to be made, without the error to which 
one is liable in making a free-hand denudation with the scissors 
alone. The first line may be made around the septum, splitting 
it at the rectal margin, and including both sphincter ends ; this 
line is continued up on each side in a curve, convex backward to the 

Fig. 195. 



fW ^ 

^J^ 


Kp 


V 


' \ 




(p\ 






f\ 




"A 




/ 


A 


, A 




) 


/ 


\ 





Rupture of the Recto-vaginal Septum: Ends of the denuded sphincter shown at the sides of the rectum. 

nymphse ; from this point lines on both sides sweep into the vagina, 
along the lateral walls, until they meet in a point up in the vagina 
a half inch or more above the incision in the septum. 

The denudation is rapidly made with a pair of curved scissors 
and a tenaculum or rat-toothed forceps. The lower parts should 
be denuded first, so that that which follows is not obscured by the 
blood. The tissue is removed in long strips until the whole area 
is thus freshened. 

The sutures are introduced as described in the immediate opera- 
tion. First, interrupted silk sutures closing the rectal side of the 
tear from the angle down to and including the sphincter, radiating 



LACERATIONS OF THE 80FT PARTS. 



2G5 



out on to the skin surface. The sphincter sutures are carefully 
introduced, so as to bring the ends accurately together. The ends 



Fig. 197. 



Fig. 196. 





Rectal Sutures in Place. 



Rectal Sutures Tied, and Sutures in place 
on the Vaginal Surface. 



of the sphincter muscle are held together, and the delicate silk 
sutures relieved of a tension they cannot stand, by one or two silk- 



FiG. 198. 





Sutures within the Vagina tied; External Sutures 
in place. 



Shaded Area indicates the extent of the Tear 
in the Recto-vaginal Septum. 



worm-gut sutures, introduced well behind one of the divided ends 
of the sphincter, sweeping around in the septum, and appearing on 
the skin at a point corresponding to the point of entrance. 



266 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The remaining sutures are passed, beginning at the upper angle 
of the denudation in the vagina, by introducing silkworm-gut 
sutures about four to the inch, and extending from the vaginal 
mucosa down to the bottom of the septum. By the time all the 
vaginal sutures have thus been introduced and tied the skin sur- 
face will appear as a shallow pit, requiring only a few silk sutures 
to bring the edges into accurate apposition. 

After the completion of the operation the urine should be drawn, 
the vagina cleansed of blood and dried out with pledgets of absorb- 
ent cotton, iodoform and boric-acid powder sprinkled over the sur- 
face and between the lips of the vulva, and a pad of loose absorbent 
cotton laid between the thighs and held in place by a T-bandage. 
The urine should not be drawn after the operation unless the 
patient is unable to pass it. Each time after urinating the vulva 
should be carefully dried with absorbent cotton and powder, and 
fresh cotton applied. The bowels should be opened not later 
than the third, preferably on the second day, and should then be 
kept open by a daily evacuation. The patient should take a pur- 
gative pill or saline purge, followed by an enema in six or eight 
hours if a natural soft movement does not follow. Extreme care 
must be observed in giving the enema not to allow the point of 
the syringe to impinge on the stitches in its introduction. 

It is not necessary to bind the limbs ; on the contrary, consider- 
able liberty of movement may be allowed without separation of the 
legs. The sutures should be removed, as in the preceding opera- 
tions, in from eight to ten days. 



GENITAL FISTULil. 



Genital fistulse are abnormal avenues of fecal or urinary dis- 
charge, by means of which some portion of the urinary tract or the 
bowel communicates with the genital tract or the exterior of the 
body. 

Fecal fistulse are formed by a communication between the rec- 
tum or the small intestine, and the uterus, vagina, or bladder. 

Urinary fistulse are formed by a ureter emptying into the 

Fig. 200. 




The Various Forms of Vesical Fistulse ; v, u, vesico-uterine ; v, v, u, vesico-vagino-uterine ; v, v, 

vesico-vaginal ; w, v, urethro-vaginal. 

uterus or vagina, by the bladder discharging into the uterus or 
vagina, or by an opening from the urethra into the vagina. 



Uketeral Fistula. 

Ureteral fistulae are sometimes congenital, discharging low down 
near the external urethral orifice : they commonly arise, however, 
from severe labors in which the laceration has extended through 
the cervix and beyond into the vault of the vagina and out into the 



261 



268 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

broad ligament, tearing the ureter. After granulation and cicatri- 
zation are completed the ureter will be found discharging into the 
uterus or vault of the vagina. 

Diagnosis. — This can be made by watching the mouth of the 
womb or the small orifice in the vault of the vagina, when the urine 
will be seen discharging at intervals of a few seconds to a minute or 
more in small jets. The patient complains of a constant discharge 
of urine, and yet she passes urine from the bladder in considerable 
quantity, which collects from the other kidney, at regular intervals. 
The injection of an aniline solution into the bladder brings no cor- 
responding discharge from the fistula ; on the contrary, its dis- 
charges remain clear. Especial care must be taken not to be mis- 
led in the diagnosis when a vesico-vaginal fistula, constantly 
draining the bladder, exists with a uretero-uterine fistula. If the 
ureteral orifice can be seen and a catheter introduced, it passes in 
the direction characteristic of the ureter ; that is, to the back part 
of the pelvis and up toward the pelvic brim, and possibly over the 
brim up toward the kidney. The intermittently flowing urine can 
be collected from the outer end of the catheter. 

Treatment. — The cure of a ureteral fistula is a matter of con- 
siderable difiiculty, and should only be undertaken by a surgeon of 
considerable skill in plastic work. 

When the ureter empties into the uterus high up out of sight, 
the corresponding kidney has been extirpated by some surgeons as 
the only means within their power of relieving the patient from the 
constant flow. The sacrifice of the kidney, however, is a procedure 
repulsive to the surgeon for the relief of a condition apparently so 
trivial. A better plan is the following : The patient is placed 
in the left lateral or the dorsal posture, and the posterior vaginal 
wall retracted with a Sims speculum. The anterior lip of the 
cervix is caught by a pair of bullet forceps and the uterus drawn 
down. If it is not evident, on account of the deep cervical lacera- 
tion and the scar-tissue, on which side the fistula lies, the cervix is 
split up until the orifice is visible. If the side on which the fistula 
is located can be detected, the cervix is separated for half or two- 
thirds of its extent from the vaginal vault and gradually drawn 
downw^ard. The cellular tissue is slowly and carefully peeled up 
on that side until the ureter is found at the fistulous orifice. 

After freeing the ureter for from a half to one inch out into the 
cellular tissue, it is severed from its uterine attachment. An antero- 



GENITAL FISTULA. 269 

posterior incision is made in the supravaginal portion of the blad- 
der about a half inch long. The end of the ureter is cut off 
quite obliquely and turned into the bladder, and the incision closed 
in such a manner as to retain the ureter in place, by passing two 
or three of the sutures which close the incision in the following 
way : the first so as to catch one side of the incision except the 
mucosa, enough of the under wall of the ureter to hold it, and the 
opposite side of the incision. The next suture catches the bladder- 
walls a little more superficially, but includes the ureter in the same 
manner. Each of the following sutures proceeding from below 
upward is passed more superficially until the upper limit of the 
incision is reached. Care must be taken not to narrow this part of 
the incision so as to compress the ureter. Two or three superficial 
sutures catching the bladder-wall and outer coat of the ureter com- 
plete the union on all sides. The incision in the vault may now be 
closed by fine silk or silkworm-gut sutures, or it may be packed 
loosely with iodoform gauze. 

Uretero-vaginal fistulse may be closed by passing a sound into the 
ureteral orifice and dissecting up the ureter for about a third of an 
inch, opening the bladder just above the end of the ureter, turning 
its end into the bladder, and closing the incision by sutures on the 
vaginal side. 

Another method is to open the bladder close to the ureteral 
orifice, and pass a catheter through the urethra and bladder and 
through the opening into the ureter. • The short portion of the 
catheter visible in the vagina is then shut in by an oval denudation 
embracing both vesical and ureteral openings. Careful transverse 
union with deep sutures of silkworm-gut and superficial sutures of 
silk then establish the channel of communication between ureter 
and bladder. 

Vesical Fistula. 

Vesico-uterine fistula ; vesico-utero- vaginal fistula ; vesico-vagi- 
nal fistula. 

Vesico-uterine Fistula. — In this form of fistula there is a direct 
communication between the bladder and cervical canal, so that the 
urine escapes constantly through the os uteri externum. The 
demonstration of the vesical involvement can easily be made by 
injecting a colored fluid into the bladder, when it will be seen to 
escape from the cervix. , . 



270 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



Treatment. — The musculo-fibrous tissue forming the cervical 
canal has a remarkable tendency to contract and close sponta- 
neously any fistulous opening arising from a severe labor. If, 
therefore, but a short time has elapsed since the receipt of the 



Fig. 201. 




Vesico-uterine Fistula. Course taken by the urine indicated by arrows. 

injury, the operator can well afford to wait a few weeks or months 
until he sees what nature alone will be able to accomplish. 

Persistent fistulse may be closed one of three ways : Where the 



Fig. 202. 




Vesico-uterine Fistula divided into two channels by a Septum of Scar-tissue. 

fistula is situated high up in the uterus and the amount of cica- 
tricial contraction in the vagina prevents a proper exposure, the 
abdomen may be opened in the median line just above the symphy- 



GENITAL FISTULA, 271 

sis, the uterus drawn out of the incision, the peritoneum incised 
transversely at the vesico-uterine fold, and the bladder carefully 
dissected from the uterus until the fistula is reached. The bladder 
should be emptied, the fistula cut through, and the opening in the 
bladder closed by a series of interrupted silk sutures, four or five 
to the half inch, including the whole wall down to the mucosa. 
The edges of the opening in the uterus should be freshened and 
drawn together by a row of interrupted silk sutures. After care- 
fully cleansing the field, the peritoneum may be re-attached to the 
uterus, the field of operation entirely concealed, and the abdomen 
closed. 

The second method is the reverse of the first, in that the vaginal 
vault is incised in front of the cervix, and the dissection carried up 
between the bladder and the uterus until the fistula is severed. This 
is closed by a row of interrupted silk sutures through the thick- 
ness of the bladder-wall, exclusive of the mucosa. The uterine 
opening may be left to itself, and a small strip of iodoform gauze 
pushed up, anterior to the cervix and under the fistula. The vagina 
is also loosely packed with gauze, which is renewed in three or four 
days. At the end of a week the pack is left out and a daily vagi- 
nal douche of a warm boric-acid solution given. 

Third Method. — Where the fistula lies near the vault of the 
vagina the cervix may be split up into the track of the fistula, 

Fig. 203. 




Vesico-utero-vaginal Fistula, in which the posterior lip of the cervix is destroyed. 

which is freshened from the bladder to the uterine surface. If 
necessary, sufiicient cervical tissue should be cut away from the 
sides of this incision, so that the denuded fistula forms the apex of 



272 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

a wedge, and is closed when the sides of the cervix are brought 
together. Silkworm-gut sutures are applied by carrying from two 
to four through from the vaginal surface of the cervix ; when these 
are tied the fistulous area is efficiently closed. The sutures should 
be removed in about ten days. 

Vesico-utero- vaginal Fistula — In fistulse of this character the 
opening is at the cervico- vaginal junction in front, median, or to 
one side of the middle line. The neighboring cervical tissue is 
cicatricial, and there is usually marked loss of substance. Where 
there is much cicatricial tissue in the cervix, it is best to draw the 
cervix downward and backward and dissect the bladder with the 
fistula free from the uterus, for a short distance above the vaginal 
vault. The fistula should then be treated by making a denudation 
extending from the vesical mucosa out on to the vaginal surface 
about a quarter of an inch broad. 

If the fistula is transverse to the axis of the vagina, the tissue 
above should be brought down to the tissue below by a row of silk- 
worm-gut sutures, entered a short distance off from the denuded 
surface and passing down to the mucosa of the bladder. These 
sutures should be passed about five to the inch. They should be 
brought snugly together without constricting the tissues. Where 
the tissue pouts between these deeper sutures, the work of approx- 
imation may be completed by superficial silk sutures. If the long 
axis of the fistula is in the axis of the vagina, the stitches should 
be passed from side to side. 

Vesico-vaginal Fistula. — A direct fistulous communication be- 
tween the bladder and the vagina is the classical affection, brought 
within the reach of the surgeon's skill by the labors of Sims and 
Emmet. These fistulse arise from protracted labors, in which the 
fistulous part of the bladder has been compressed sufficiently long, 
between the head of the child and the symphysis pubis, to produce 
a slough, wliich comes away in from three days to a week after labor, 
leaving the artificial opening. It may also arise from direct injury 
of the tissue while using the forceps ; they are more often the con- 
sequence, however, of the want of the forceps to obviate the delay. 

These fistulse vary in size from a pin-point to one or two inches 
in diameter. The small ones are usually the remains of an unsuccess- 
ful attempt to close a larger fistula. In form, a vesico-vaginal fistula 
is round, oval, or irregular. One of the most important complica- 
tions of the condition is a cicatricial contraction of the vagina and 



GENITAL FISTULA, 273 

the presence of cicatricial bands extending from the fistula out on 
to the vaginal walls. 

Treatment. — Where the vagina is contracted by scar-tissue, this 
must be divided in one or more places and stretched so as to aiford 
an ample exposure of the fistula. The attempted closure of the 

Fig. 204. 




Vesico- vaginal Fistula ; bladder adherent to the uterus along the darkly -shaded line. 

fistula will succeed in direct ratio to the satisfactory exposure, which 
allows every step of the operation to be accurately conducted. 

If the vagina is eroded and coated with phosphatic concretions, 
this condition should be relieved by weak warm boric-acid douches — 
about a teaspoonful to the quart — and the erosions should be occa- 
sionally touched with a solution of nitrate of silver, about 5 or 
10 grains to the ounce. The operation can be most conveniently 
performed with the patient in the lithotomy position, with well- 
flexed thighs held up on the abdomen by a leg-holder and the 
buttocks resting on the perineal pad for drainage. The poste- 
rior vaginal wall is then retracted by a Sims speculum. The 
denudation of the margins of the fistula is made by marking with 
a sharp knife the outer limit of the area to be denuded, from a 
quarter to an eighth of an inch from the edge of the fistula. With 
a fine right-angled tenaculum or a pair of long fine rat-tooth for- 
ceps the operator catches hold of a piece of the tissue thus out- 
lined, lifts it up a little, and proceeds to denude the whole down 
to the mucous membrane of the bladder. The denudation may 
be accomplished with a sharp small-bladed knife, but it will 
be more easily made by means of a long pair of scissors, with 
delicate blades coming to a sharp point, slightly curved on the flat 

18 



274 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



surface. No undenuded islets of tissue should be left to interfere 
with the union after approximation. The direction in which the 
tissues should be brought together depends upon the form and size 
of the fistula. In the case of small fistulse it is immaterial; in cir- 
cular fistulse the vaginal tissue yields most readily in drawing the 
upper border down to the lower, shortening the vagina, and placing 
the scar across its axis. A long, oblique fistula should be approx- 
imated in the direction of its long axis. The edges of a round 
fistula cannot be accurately brought together, and it becomes often- 
times necessary to dissect out a V-shaped piece at each end of the 
fistula, rendering the opening elongated and its edges easy of 
approximation. Two sorts of sutures should be used in approx- 
imating the denuded margins — silkworm-gut for the deep, and fine 
silk for the superficial stitches. 

The sutures should be applied by means of a small curved needle 
with a silk loop as a carrier. The first one may be placed at 
either end or often, conveniently, in the middle. If the fistula 
is a large one it may be tied at once, facilitating the even closure on 
both sides of it. Each silkworm-gut suture should enter the vagi- 
nal mucosa from an eighth to a sixteenth of an inch from the edge 
of the denudation and appear at the margin of the mucous mem- 
brane of the bladder, to re-enter at the mucous margin on the 

Fig. 205. 




Operation for Vesico-vaginal Fistula. Bladder dissected away from uterus, and stitches intro- 
duced preparatory to closure. 



opposite side and reappear on the vaginal mucosa at a point cor- 
responding to the point of entrance. No suture should be allowed 
to penetrate the mucous membrane of the bladder, else it is liable 
to become the point of a future fistula. Five or six similar sutures 
to the inch should be inserted, and one just at or just beyond each 
angle. These sutures should then be brought together and tied 



GENITAL FISTULjE. 275 

snugly, approximating the tissues without strangulation. The 
pouting tissue between these deep stitches should be approxi- 
mated by fine silk ones. 

The ends of the sutures should be cut about a half inch long, 
and a loose iodoform gauze pack placed in the vagina. Should 
there be any tension whatever upon the sutures, longitudinal incis- 
ions should be made deep in the scar-tissue on both sides of the 
fistulous opening until all tendency to tension is relieved. These 
incisions should be made short, so that they may be closed by 
stitches introduced in the direction of their long axes, thus further 
relieving the tension. This precaution is oftentimes absolutely nec- 
essary to the success of the operation on the fistula. 

Under no circumstances should a sigmoid or other catheter be 
placed in the bladder for permanent drainage. 

For the first three days the patient should be catheterized every 
three hours, after which she may be allowed to void her urine, 
taking care not to hold it longer than six hours, until the sixth 
day, when she may be allowed to pass the night without waking. 
In the case of smaller fistulse the patient mav void her urine from 
the very first. If the vaginal pack becomes wet or soiled, it should 
be removed at once, otherwise it may be left in place for two days, 
when it should be removed and the vagina allowed to remain empty. 
It is not necessary to use a vaginal douche at any time unless there 
is a discharge from the vagina. All the sutures should be removed 
in from eight to ten days. 

Urethral Fistulce. — A fistula following labor and involving the 
urethra is usually small and of its interior half — that part pro- 
jecting into the vagina. Fistulae in the long axis of the urethra 
are at times made artificially by Emmet's operation, to relieve vesi- 
cal tenesmus. In closing the fistula, if small, the denudation may 
extend in a circle around it in a manner similar to the vesico-vagi- 
nal fistula ; if large, a wedge may be cut out of the under part of 
the urethra with the fistula at its base, and the denuded surfaces 
brought together by silk sutures, extending down to the mucosa 
and applied close together and with extreme accuracy. 

Fecal Fistula. 

Fecal fistulse are abnormal avenues for the escape of the con- 
tents of the small or large bowel, either by the vagina or the blad- 
der. The laro-e bowel is almost invariablv involved. The fistu- 



276 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

lous orifice, having no sphincter, affords an avenue for the con- 
stant escape of fecal matter when tiie contents of the bowel are 
fluid. If the fistula is small, opening into the sigmoid flexure or 
rectum, and the contents of the bowel formed, the escape of feces 
may occur but rarely. 

One of the most common and distressing symptoms of these fis- 
tulse is the more or less frequent escape of intestinal gases, which 
pass out with an audible bubbling or hissing noise, and by the evi- 
dent odor, distresses the patient, so that she finally entirely avoids 
society and remains at home brooding over her ailment. 

Recto-vaginal Fistula. — Recto- vaginal fistulse are the most fre- 
quent; they consist in a communication between the rectum and 
the vagina through the recto-vaginal septum, at some point between 
the cervix uteri and the vulva. 

Recto-vaginal fistulee in the upper part of the vagina are not 
uncommon sequelae of a cancer of the cervix uteri, due to a destruc- 
tion of the upper part of the septum. In most of the cases of this 
class the disease is already in its last stages, and nothing can be done 
to cure the affection. The duty of the physician is limited to keep- 
ing the parts as clean as possible by repeated irrigations with warm 
water slightly medicated with boric or carbolic acid. 

Recto-vaginal fistulse in the lower part of the vagina and recto- 
vulval fistulse commonly arise from imperfect union of the tissues 
after an attempt to repair a complete tear of the septum. When 
these fistulse are reduced to the size of a pin's head, the closure may 
be effected by stimulating the tract with cantharidis or a little nitric 
acid. 

, Fistulse may be closed by making a broad denudation, extend- 
ing from the sound tissue, around and deep down into the fistula, 
and then passing sutures, one or two deep, of silkworm-gut, and 
the remainder of silk, from side to side, just as in a vesico-vagi- 
nal fistula operation. A loose iodoform gauze pack should be 
placed in the vagina. On the eighth day all sutures should be 
removed. 

When the fistula is bounded on one side by a thin band of cica- 
tricial tissue or is much over a sixteenth of an inch in diameter, the 
best course to pursue in its treatment is usually to cut through the 
scar-tissue, thoroughly denude the fistulous area, thus reproducing 
the original injury, and secure snug apposition throughout with 
greater ease and without constricting the tissues. 



GENITAL FISTULA. 277 

The suture and after-treatment of these cases is similar to that 
of the cases of complete tear of the septum. 

When the small intestine opens into the bladder at some point 
within the upper pelvic cavity, the only plan of treatment is to 
open the abdomen, find the fistulous tract, and sever the adherent 
intestine from the bladder, taking care, when necessary, to sacri- 
fice rather the bladder than the bowel. This part of the operation 
will usually prove difiicult, owing to numerous surrounding adhe- 
sions among the bowels, which must be separted with pains-taking 
care. After loosening the knuckle of bowel from the bladder, 
each viscus should be carefully protected by thick pieces of gauze 
to avoid contamination of the surrounding peritoneum, and the 
opening, first of the intestine, then of the bladder, should be closed 
by a sero-muscular or a rectangular suture. 



DISTORTIONS AND MALPOSITIONS. 



Distortions and malpositions of the uterus may result from 
incomplete laparotomies or those in which drainage has been em- 
ployed. Adhesions forming around the drain produce the most 
fantastic twists and bends in the uterus. Neoplasms and diseases 
of adjoining organs also cause flexions and displacements of the 
uterus, but such conditions will not be described here. 

The more common forms are anteflexion, retroflexion, retrover- 
sion, prolapsus, and inversion. It must be born in mind that there 
is no position of the organ which is normal to all women. The 
uterus is a movable body, varying in its position in answer to the 
condition of the bladder, rectum, and other pelvic and abdominal 
organs. It must not be assumed because a given womb be found 
with its fundus behind the long axis of the pelvis, in a retroflexed 
or retroverted position, or before it, in an anteverted or anteflexed 
position, that the symptoms from which the woman is suffering 
come from the womb. Any of these positions may exist and be 
perfectly natural and normal to that particular individual. 

Pathological Anteversion is described by some authors, but we 
have never seen a case unless the uterus were displaced by a neo- 
plasm, or adhesions or the distortion of some adjacent organ was 
to blame for the malposition. The uterus naturally follows the 
movements of the bladder, and is distinctly normally anteverted 
when the bladder is empty. 

Anteflexion. 
This occurs in two chief forms. In simple anteflexion the axis 
of the cervix and the cervix itself occupy to the vagina a normal 
relation. But the body is sharply bent upon the cervix. These 
uteri are found high in the pelvis, drawn up toward the promon- 
tory of the sacrum. The uterus is somewhat fixed in that posi- 
tion, limiting downward mobility. The result is that while the 

278 



DISTORTIONS AND MALPOSITIONS, 



279 



woman is erect the entire intra-abdominal pressure falls directly 
upon the posterior aspect of the uterus, and the condition is still 
more aggravated. Whether this flexion be due to inflammatory 
shortening of the utero-sacral ligaments, thus drawing up the 
cervix, is not proven, but possibly such is the case. The cervix is 
short and fairly well open, but sometimes stenotic. The sound 
shows the depth of the uterus to be normal and the point of flexure 
at the internal os, or the whole organ may be of much decreased 
size (infantile uterus). The posterior wall opposite the flexure is 



Fig. 206. 




Diagram of Pathological Anteflexion arising from contraction of the folds of Douglas : a, direction of the 
traction of the folds ; 6, that of intra-abdominal pressure. 

thinned, while the anterior is thickened. The endometrium is 
usually atrophied and poor in lymphoid elements. This is the 
common picture. But there may instead be marked hypertrophy. 
The cervical canal has lost much of its slit-like form, and is more 
tubular. 

Symptoms. — The patient usually gives some such history as this : 
she menstruates regularly. A few hours before the flow appears 
there is a good deal of pain located behind the pubes, intermittent 
and crampy in character, or continuous, severe, and with spas- 



280 AJV AMERICAN TEXT-BOOK OF GYNECOLOGY, 

modic exacerbations. A clotted flow appears which affords re- 
lief for a time. She uses one or two napkins the first day or so, 
and after lasting two or three days the flow becomes thin and 
watery. It is followed for a longer or shorter time by a milky dis- 
charge which is unirritating, but disagreeable. When the patient 
is up she has to urinate frequently, but is not troubled at night. 
Upon examination the uterus is found high up, the cervix small, 
and the fundus is easily detected as a rounded nodule above the 
anterior lip. Rectal examination is exceedingly valuable, in that 
it determines the absence of the fundus from its normal position. 
If it is necessary to use the sound, the instrument shows the flexure 
and its degree. Before being passed it should be bent to the appar- 
ent angle of the flexure, and no force should be used in its intro- 
duction. Downward traction on the uterus by a tenaculum lessens 
the degree of bend and facilitates the introduction of the instru- 
ment. The cervical plug of mucus is opaque and milky or clear, 
seldom purulent. Secondary cervical erosion and inflammation is 
not common. The appearance of the cervix varies greatly in dif- 
ferent cases. Commonly the external os is a rounded hole, and the 
cervix more or less conical. The narrowing of the canal may be so 
marked that a probe is with great difficulty introduced. This is 
of no great diagnostic importance, as it is rare that the outlines 
of the uterus cannot be detected by the bimanual touch. These 
cases are commonly associated with vaginismus in the unmarried 
and with dyspareunia and sterility in the married. 

The other common form of anteflexion is still more interesting, 
and may be designated as anteflexion with retroversion. The body 
of the uterus occupies nearly a normal relationship to the bladder 
and pelvic walls, or may be somewhat retroverted. The cervix is 
so sharply bent upon the body that its axis is the same as that of 
the vagina. It is always hypertrophied, and may even be so long 
as to project from the vulva. The whole organ is somewhat lower 
in the pelvis than normal. The condition is really one of hyper- 
trophied cervix bent upon the body, with, possibly, some retropo- 
sition and descent of the latter. The greater the hypertrophy the 
more the descent and backward displacement of the body. 

Examination shows the enlarged cervix, often with a conical 
end and circular os externum. The body is not always felt per 
vaginam, but is readily found by rectal examination. 

Because of the elongation of the cervix, introduction of the sound 



DISTORTIONS AND MALPOSITIONS. 281 

is difficult. The total length of the canal is increased, but that of 
the body is about normal. If the organ be pushed high in the 
pelvis, the cervical elongation decreases, and the fundus falls for- 
ward on the bladder. The posterior lip is much longer than the 
anterior. The endometrium is the seat of hypertrophic changes, 
especially at the os internum. Downward traction increases the 
backward tendency of the body. 

It is an interesting fact that in all these cases of anteflexion the 
bladder is attached to the uterus abnormally high. 

So far, no attempt has been made to explain the pathogeny of 
the^e two lesions. That simple anteflexion is associated with short- 
ening of the utero-sacral ligaments is undoubted. Whether this 
shortening be congenital or acquired may possibly be determined. 
Transverse sections of the child show that the os internum occu- 
pies a position relative to a line drawn from the symphysis to the 
end of the last sacral vertebra, much higher than in the adult. 
If any disease of infancy should decrease the elasticity of the utero- 
sacral ligaments, as the body grows, the cervix being fixed, it will 
fall forward on the bladder. The continuous force of intra-abdom- 
inal pressure, together with its increase by lacing, adds to the nat- 
ural tendency the uterus has to bend. Also when the organ is 
gorged with blood at the menses, and the body erect with that 
pressure, still more will it bend. 

In infancy the cervix is relatively large, but the hypertrophy we 
see accompanying certain flexions cannot be accounted for. It is 
utterly unlike any that occurs as the result of inflammation in the 
adult organ. Probably the process is begun even before birth or in 
early infancy. Inasmuch as the cervix is first developed, the 
explanation may be found in some stimulus, giving this an impetus 
too early or too strong, resulting in unbalanced growth later on. 

These patients have more flow than those suffering from simple 
anteflexion, and the pain is not so great ; the blood does not clot as 
much. There is the same leucorrhea, and more of it. Backache 
and pelvic tenesmus are constantly present. Vaginismus and local 
nervous disturbances are common. The married are usually 
sterile. 

An explanation of the symptoms is here called for. The dys- 
menorrhea is due, not to the obstruction to the flow of blood, as 
stated by authorities, but solely to the manner in which the flow 
is produced, and the character of the blood. The epithelium, 



282 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

instead of melting off, comes away in blocks and shreds. Casts of 
whole follicles may form. The blood is produced in too sudden a 
manner at first, and is sparsely mixed with lymphoid cells, and 
hence coagulates, instead of remaining fluid. The pain is produced 
because the endometrium is altered in essential particulars and 
because of the blood-clots. In those cases where the blood clots least 
the dysmenorrhea is least. We grant that all this is secondary to 
the flexure, the bend causing altered nutrition and perverted nerve- 
impulse. But it is to the altered condition of endometrium that the 
dysmenorrhea is due. The vaginismus and dyspareunia are purely 
secondary and dependent upon the nerve-irritation produced by the 
dysmenorrhea. 

The subject of sterility of uterine origin can be dismissed in a 
few words. 

Women with these flexed uteri who marry early in life, before 
the endometrium has undergone the structural changes described 
under the head of " Simple Endometritis " — conceive as readily as 
other women, although they may suffer from the most severe dys- 
menorrhea from clotting of the blood. It is as illogical to assume 
that a canal which admits a Simpson sound will refuse entrance to 
a spermatozoon, as that a spermatozoon may penetrate the minute 
Fallopian opening and yet not be able to enter the cervical canal 
in such cases as these under discussion. The obstruction theory 
of Sims and his followers will not meet the objections raised by 
more recent physiological and pathological investigations. The 
whole fabric of the uterus is made for the proper management 
of the placenta- forming endometrium. If this be markedly and 
generally diseased, its chief function is gone. The requirements 
on the part of the woman to conception are — patent tubes, dis- 
charge of an ovule, melting off of the epithelium from the sur- 
face of the endometrium, and engorgement of the retiform tissue 
by lymphoid elements. If these requirements are not satisfied, 
conception does not occur. Flexure undoubtedly produces degen- 
erative changes in the endometrium, but it is those changes, and not 
the flexure, which prevents conception. 

Therefore, with a wrong interpretation of the menstrual func- 
tion, and seeing but the grosser lesions, gynecologists have been 
but partial in their treatment of these lesions and the attending 
sterility. 

Treatment. — The indications seem to be to relieve that lesion 



DISTORTIONS AND MALPOSITIONS. 283 

which produces the changes in the endometrium and give the woman 
a new cystogenic membrane. In the first form of anteflexion, the 
uterus is dilated thoroughly and washed out with boracic-acid solu- 
tion. Now comes the essential part of the operation, for which the 
dilatation is merely preparatory. As thoroughly as possible the 
whole inside of the uterus is curetted, removing every possible ves- 
tige of the endometrium. The cavity is again washed out. Iodo- 
form gauze is then tightly packed into the uterus and the vagina 
lightly filled with the same, this being left in six days. It is then 
removed and no further treatment given. 

The operation is best done two weeks before a period. The 
patient is allowed out of bed on the third day ; she should remain 
in the house three weeks. If the operation is done for sterility, 
and if there be no suspicion of gonococci in the husband's urethra, 
connection should take place two days before the menstruation and 
immediately after. No pessary is used or needed. 

Anteflexion with i^etroversion is treated on the same principle — 
removal of the endometrium and relief of that condition which 
originally produced it. Here the latter is more difficult than in 
simple anteflexion. The uterus is steadied by the bullet forceps, 
and not drawn down much ; the canal is dilated cautiously, 
to half an inch, after this the uterus is washed out, thoroughly 
curetted, again irrigated and packed tightly with iodoform gauze, 
and the usual vaginal dressing applied. The packing is removed 
on the fifth day, and a light drain of gauze introduced just 
through the internal os ; no pain is produced. This second 
dressing remains in three days more, and another is applied. The 
drains should be introduced for two weeks. The curettage is the 
important feature. Pessaries are out of place in the treatment. 

After the operation, atrophy of the elongated cervix rapidly 
supervenes. Also, the uterus, relieved of the weight of the enlarged 
cervix, rises in the pelvis and assumes a more forward position. 
Should the cervix be much elongated or hypertrophied, it should 
be amputated. Both the amputation and the curettement may be 
carried out at the same sitting. 

If it be decided to amputate the hypertrophied cervix, not more 
should be removed than two-thirds of that which it is desired shall 
be the ultimate decrease in size. Atrophy incident to the operation 
will remove the rest. If the hypertrophy be so great as to require 
amputation, the operation for amputation, to be described, is recom- 



284 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

mended, and at the same time the cervix is dilated and the uterus 
curetted. 

There are still those in America who teach and practise the use 
of stem pessaries. Inasmuch as for years we were so placed that 
daily we could observe the results of their use, we feel qualified to 
speak on the subject. Those who use them consider the cervical 
stenosis as the objective point. Having made incisions of the cer- 
vix, the uterus is not washed out and is not curetted, but dilatation 
is done. The pessary is then introduced and retained in place by 
a cotton tampon in the vagina. It is removed in three days, and 
an application of iodine or carbolic acid made to the endometrium, 
and the stem again put back. If the uterus be simply anteflexed, 
the stem will stay in without support ; but if the cervix looks out 
in the axis of the vagina, the stem must be retained in place. 
These stems are straight and forced into place in the flexed canal. 
They act, according to those who employ them, by straightening the 
canal and establishing drainage. They keep the incised and dilated 
canals open without doubt, and, as they are left in during the menses, 
connection, and douching, the discharges are very profuse — more 
profuse, in fact, than before they were used ; hence their advocates 
consider that they are draining away discharges, when in reality 
they are producing them. Under their use and the applications 
fair success is obtained after six months' treatment. 

Now, if the sterility and dysmenorrhea were due, as maintained 
by nearly all stem-pessary men, to the stenosis, they should be at 
once cured by the operation. But tliese gentlemen treat the endo- 
metrium for a long time to '^get the secretions healthy," they con- 
sidering that spermatozoa will not live in purulent secretions, in 
spite of the fact that the emissions of every gleety man are filled 
with them. They do not know that the fault lies with the struc- 
turally changed endometrium. Their applications do some good, 
but it is tardy and comes when the patient is about worn out with 
treatment. The percentage cannot be estimated accurately, but we 
have known so many inflamed tubes come from this treatment that 
we believe they do nearly as much harm as good. If used in a case 
of simple endometritis, that speedily becomes purulent. 

The stem pessary requires months to accomplish a result ; it pro- 
duces pus, it frequently causes inflammation in the tubes and peri- 
toneum, it does not drain, and it does not cure endometritis. The 
sole beneficial feature in this method lies in the application of iodine 



DISTORTIONS AND MALPOSITIONS. 285 

and carbolic acid. Contrast this with the procedure offered here. 
We have seen conception follow within five days after a curettage, 
and it is the usual result at the second or third period following 
the operation. There is produced no pus, there is no long treat- 
ment, there are no accidents, and the results are usually immediate 
relief from the dysmenorrhea. 

It but remains for us to say that the treatment of anteflexion by 
the stem pessary is not based upon accurate ideas of the lesion and 
the function of the endometrium. 

We repeat, *the object of the whole operation is to give these 
women new endometria, forming under propitious circumstances, 
and as soon as possible to obtain conception in the married. In the 
unmarried the relief from the dysmenorrhea is often permanent. 

There is another procedure which, while it has little effect upon 
the condition of the endometrium, affords temporary relief from 
dysmenorrhea. We refer to dilatation without curettage. The use 
of the dilator without ether is exceedingly painful in these sensitive 
women ; it is of but temporary benefit, and must be repeated many 
times ; it is done under conditions where exact asepsis is impossible, 
and therefore has attached to it the risk of infection ; and, further- 
more, it occupies a middle position between operation and treatment^ 
with none of the good results of the former, and all the dangers of 
the latter, in most hands. Long after-treatment of these nervous 
w^omen is inadvisable, because it keeps constantly before them 
their malady. They become hypochondriacal and utterly miser- 
able, and prone to magnify their really trivial troubles. 

There are many cases where it is difficult to decide what opera- 
tion to do. The two factors which guide us in the selection are the 
amount of cervical hypertrophy and the axis of the cervical canal 
to that of the vagina, this being normally about 50°-60°. 

In all the intra-uterine manipulations the most precise asepsis 
must be observed, lest we convert a simple into a septic endometritis 
and extend a septic endometritis into a tubal or peritonitic involve- 
ment. A woman who has once had either complication occupies a 
position in society far different from one who has not, and goes 
through her life with the possibility of a celiotomy ever before 
her. 

With this caution we may say that dilatation may be done so as 
to do the patient no possible harm if the proper precautions be 
taken. Still, it is an undoubted fact that the instrument has been 



286 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

most recklessly used. If curettage is not adopted, dilatation once 
every month, a few days before menstruation, will give most patients 
much relief from pain. But our experience is that the method is 
applicable to cases of short cervix only. 

Latekal Flexions. 

These are generally the result of some inflammatory lesion out- 
side the uterus, such as adhesions, and of that common form of con- 
traction in one broad ligament which follows puerperal septic sal- 
pingitis. They are not amenable to extra-peritoneal treatment, and 
are purely secondary. 

Anteflexion Complicated by the Menopause. 

AVhen the menopause occurs in old maids with anteflexion, it pro- 
duces a very distressing train of nervous phenomena which prop- 
erly come to the attention of the gynecic surgeon. The fundus 
rapidly atrophies and leaves the cervix proportionally much en- 
larged. The cervix also finally retrogrades, the nerves are caught 
and compressed in the shrinking tissue, and the discharges are 
retained. The os is but pin-hole in character, and the whole 
cervical canal much decreased in dimensions. These uteri are 
originally but poorly and irregularly developed, their owners go 
through life suffering from dysmenorrhea, and when the menopause 
comes the atrophy takes place irregularly. They are complicated 
by a simple endometritis. All the treatment that is needed is 
dilatation of the cervix. The curette and gauze packing are 
seldom required for the endometrium, but it is better to introduce 
a filament of gauze into the cervix, leaving it in for a week, 
with a gauze vaginal dressing. No after-treatment is necessary. 

These cases are often subjected to the stem pessary and elec- 
trical current. Being high-strung, nervous, almost irrational 
creatures, long continued local treatment has a deleterious effect 
upon both their mental and moral qualities. Medicinal treatment 
can give them little or no relief. If surgical aid be refused it 
becomes necessary to resort to opiates in some form at each recur- 
ring monthly period. Such treatment, although effective, is 
exceedingly dangerous, and should only be practised when all 
else fails. Such methods of relief as are given in the chapter 
on Dysmenorrhea should be tried before resorting to the use of 
this drug. 



DISTORTIONS AND MALPOSITIONS, 287 

Retroflexion and Retroversion. 

Congenital retroflexion is exceedingly rare. It is found in single 
or sterile married women. The uterus is invariably back in the 
pelvis and the organ sharply bent upon itself, the flexure being at 
the OS internum. The cervix is normal or slightly below normal in 
size. The flexure is exceedingly sharp, the fundus occupying the 
cul-de-sac. In rare cases no sulcus can be felt between the cervix 
and the body. The body is usually adherent to the rectum, render- 
ing the deformity irreducible. The anterior wall opposite the inter- 
nal OS is so thinned as to be but membranous, while the posterior is 
much thickened. Schultze attempts to explain uterine flexures by 
ascribing them to intra-abdominal pressure, acting upon the uterus 
at some point fixed by inflammatory tissue, and describes a retro- 
flexion due to fixation of the cervix anteriorly. The dilating and 
contracting bladder renders such a condition all but impossible. It 
is surely so where the flexure is congenital. So rare is this condi- 
tion that Winckel describes but four cases. The uterus is close 
to the sacral curve and not lower than normal. It seems to be 
displaced directly backward. The fundus presses upon the rectum, 
and the total length of the uterine canal is decreased. All have 
some form of endometritis, rarely purulent. The ovaries and tubes 
are usually normal in position, and do not follow the fundus. 
The symptoms are uniform, with trifling variations : continuous, 
severe backache; pelvic tenesmus; difiicult defecation and the 
passage of small stools; frequent headaches (occipital), especially 



Fig. 207. 




Extreme Ketroflexion. 



at the periods; dysmenorrhea, severe and identical with that 
accompanying anteflexion, with a scanty flow and passage of clots. 



288 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Bimanual examination reveals the direction of the canaL The 
bladder is attached to the uterus below the level of the internal os. 
Rectal examination, combined with abdominal palpation, detects 
the degree of flexure, and the intimate approximation of the cervix 
and fundus. 

Treatment. — The indications are for the establishment of thor- 
ough drainage. Replacement is impossible by the use of the 
sound or by manipulations, even under ether. 

The Operation. — The posterior lip is incised through from above 
the internal os ; the uterus is dilated, curetted, and irrigated. The 
hemorrhage is free, inasmuch as the circular vessels are cut. To 
check this, tight iodoform gauze tamponade is indicated, to be 
retained in place by vaginal gauze tampons for at least two 
days. It is then removed and gauze packing substituted. The 
treatment lasts for three weeks. The headaches disappear, as does 
also the dysmenorrhea. With the short vaginae and structurally 
altered uteri, we cannot see how Alexander's operation or ventro- 
fixation could possibly be of benefit, and pessaries are worse than 
useless. 

Acquired Retroflexion and Retroversion. 

Etiology. — Retroflexions and retroversions caused by tumors 
will not be described. 

Retroposition of the uterus may ensue as a result of conditions 
in its own tissues and from lesions in the supporting structures. 
Any factor tending to enlargement of the uterus, which at the same 
time softens its walls, may cause retroposition. Such are pregnancy, 
septic endometritis, and subinvolution. There is so much discrep- 
ancy in the relative frequency of retroflexion and retroversion given 
by different authors that it is impossible to furnish an accurate 
ratio. Retropositions are frequently found after the adnexa of 
both sides have been removed, without adopting some means to 
retain the uterus in its proper position. 

The cervix being more or less a fixed point, the heavy and 
softened body falls backward. A very common cause is too long 
confinement in the dorsal position in bed after labor, especially as 
the uterus is apt to be, under these circumstances, in a pathological 
state. 

A sudden fall from a height, producing rupture of the round, 
broad or utero-sacral ligaments, a sudden increase of the intra- 



DISTORTIONS AND MALPOSITIONS, 289 

abdominal pressure, as the body being crushed under a weight, may 
produce retropositions of the uterus by interference with its supports ; 
or, they may be produced by a lesser and more gradual increase in 
the intra-abdominal pressure, operating for some time upon a soft- 
ened uterus. But the common association of causes is a break in 
the pelvic floor, together with uterine enlargement. 

The chief single cause is rupture of the perineum. The walls 
of the collapsed bladder completely fill the space between the 
uterus and pubes ; therefore displacement forward is possible to 
but a very slight degree. The perineum being torn, the sphincter 
ani does not feel the full opposing force of the levator ani in defeca- 
tion, so more or less straining at stool becomes necessary. The result 
is that the feces, meeting the closed sphincter, seek a relief from the 
intra-abdominal pressure in the direction of the posterior vaginal 
wall, causing it to bulge forward. This drags on the posterior lip 
of the cervix, the uterine axis approaches that of the vagina, and 
the whole organ descends a little. If the uterus be enlarged as 
from a recent pregnancy, it will, yielding to the pressure from 
above, either fall backward or its fundus will bend upon the cervix, 
causing a flexion. 

Retroverted and retroflexed uteri are as low in the pelvis as are 
the anteflexed uteri high up. 

The element of intra-abdominal pressure is operating continu- 
ously, and may, apart from defecation, cause the displacements men- 
tioned, where the supports are broken, more especially when there 
is a lack of tone in the uterine muscle. 

Septic conditions, especially those acutely established in an abort- 
ing uterus, frequently result in acute retroflexions, which disappear 
in a few days if the sepsis is removed, and the uterine muscle regains 
its tone. Pelvic peritonitis and inflammatory processes in the tubes 
and ovaries also cause retropositions by the formation of false bands. 

The results of persistent retroflexion and retroversion are, endo- 
metritis from poor drainage and the formation of adhesions to the 
bowel. In addition to this, certain irregular changes take place in 
the muscularis, such as thinning of the anterior and thickening of 
the posterior wall. The broad ligaments are twisted and the ven- 
ous circulation retarded, leading to a varicose condition of the pam- 
piniform plexus. This in time predisposes to prolapse of the ovaries 
and tubes. Retroposition is the first step to prolapsus. 

Symptoms. — Women with retroversion or retroflexion complain 

19 



290 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



more of backache and a dragging sensation in the pelvis than of 
any other symptoms. These may be so great as to amount to act- 



FiG. 208. 




Ventro-recto-vaginal Reduction in Uterine Retrodisplacement. 

ual inability to walk. Leucorrhea is a prominent symptom, the dis- 
charge being milky or purulent. As a result, erosions of the cervix 

Fig. 209. 




Bimanual Reposition of the Retroflexed Uterus : first step. 

may occur. In septic or inflamed uteri every movement is felt in 
the tender organ. Defecation is difficult and often painful, hence 



DISTOBTIONS AND MALPOSITIONS. 



291 



postponed as long as possible. Costiveness results, with the com- 
mon accompanying train of anorexia, foul breath, etc. Dragging 
upon the bladder often causes the sphincter vesicae to leak, and 
dribbling of urine occurs upon laughing or exertion. Pains down 
the front of the thighs are frequent, and are increased on motion. 
Occipital headache and burning pain in the nuchse, inability to con- 
centrate the thoughts, melancholia, hysteria, and peevishness are 
common reflex nervous phenomena. The endometrium commonly 

Fig. 210. 




Bimanual Keposition of the Retroflexed Uterus : second step. 

becomes hypertrophic, and gives rise to increased menstrual flow. 
This, however, is not painful as a rule, owing to the fluid condi- 
tion of the blood and patency of the canal. 

Upon examining these cases of posterior displacement, the uterus 
is found low in the pelvis. If there be pronounced retroversion, 
the finger first touches the posterior lip of the cervix, and the uter- 
ine tissue continues from this point backward and downward. There 
is absence of the body from its normal position, and rectal touch 
demonstrates its presence in the cul-de-sac in retroflexion ; in retro- 
version the body presses on the rectum higher up. In aggravated 



292 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



cases the ovaries also lie so low as to be easily felt to either side of 
the uterus. The fundus is tender, and more or less enlarged accord- 
ing as the displacement occurs post-partum or not. 

The local tenderness and size, with many of the subjective symp- 
toms, vary greatly according to the causative factors. 

Retropositions of the post-partum uterus, or the organ materially 
softened by endometritis and metritis, have commonly both versions 
and flexions associated. Therefore one author will describe a cer- 
tain case as retroflexion, while another places it as retroversion. If 
the uterus be flexed to any extent, there will be a convexity on the 

Fig. 211. 




Bimanual Reposition of the Retroflexed Uterus ; elevation of the fundus by the Internal hand. 

anterior surface of the organ where normally there should be a con- 
cavity, and the reverse on the posterior border. The finger in the 
rectum, with abdominal palpation, makes the diagnosis absolute, for 
every portion of the organ can thus be reached. In all cases, when 
necessary, the sound will demonstrate the direction of the uterine 
canal. It is a matter of importance to determine whether or not 
the uterus can be replaced or whether it is adherent to the rectum. 
Before doing this one should know that there is no suppurative 
focus in the tubes or ovaries. If also there be no septic endome- 
tritis, one of four methods may be adopted : replacement by the 



DISTORTIONS AND MALPOSITIONS, 



293 



hands alone, by the knee-chest position, by the sound, or by the 
repositor. 

In thin women only can the uterus be replaced with ease by the 
unaided hands. In fat women it is often rather difficult, and is 
then best accomplished by means of the finger in the rectum, or by 
the knee-chest position. These two methods have great advantage 
over all others in that they are applicable to cases with septic endo- 
metritis, for they do not necessitate invasion of the inside of the 
uterus. They should be tried faithfully and persistently before 
resorting to other means. These two methods of replacement are 

Fig. 212. 




Bimanual Reposition of the Retroflexed Uterus; the external hand taking charge of the fundus. 

the only ones which give good results. Rare indeed must be the 
cases in which they fail when properly tried. 

Bimanual Reposition: The patient assumes the half-reclining 
posture, with the knees flexed on the abdomen and the clothes per- 
fectly loose. The finger is introduced into the vagina and passed 
behind the cervix. The tip is gently bent and attempts are made 
to pull the cervix forward toward the symphysis pubis. The free 
hand on the abdomen is crowded down hard, following the curve of 



294 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



the sacrum. The object is to keep as far back in the pelvis with 
this hand as possible, and to pin the retroposed uterus against the 
symphysis. No attempt has so far been made at reduction — merely 
the preliminary step of fixing the organ. The vaginal finger is now 
carried behind the body, which is lifted as high as possible along 
the curve of the hand pushed into the abdomen, until it is well 
in front of the fingers of the free hand. This is then moved 
slowly forward toward the pubis until resistance is met with. 
This maneuvre bends the body of the uterus upon the cervix. 

Fig. 213. 




Bimanual Reposition of the Retroflexed Uterus, completed. 

The vaginal finger is then placed in front of the anterior lip of 
the cervix, and this is pushed upward and backward to the pro- 
montory of the sacrum, while at the same time the body is held 
anteriorly. The last movement is to suddenly push the cervix 



DISTORTIONS AND MALPOSITIONS. 



295 



forward in a straight line toward the symphysis by the finger 
behind the os tincse. The uterus is now in an anteverted posi- 
tion. If the cervix is held high in this position while the patient 
gets up and stands, the intestines will fall behind the uterus and 
the intra-abdominal pressure keep it in place. 

Knee-chest Repositio'a. — The patient is placed in the knee-chest 
position and the perineum is lifted up with a Sims speculum. This 

Fig. 214. 




uterine Repositor. 

at once allows the intestines to fall away from the pelvis into the 
abdominal cavity. The cervix, thus exposed, is caught up with 
a tenaculum and drawn well forward toward the vulvar orifice. By 
this movement the fundus is drawn forward sufficiently for it to 
swing past the promontory of the sacrum, by the aid of gravity, 

Fig. 215. 




Replacement of Retrodisplaced Uterus by means of the Uteriue Repositor, with the patient in the knee- 
chest position. 

which it will do in a small proportion of cases. Should it not do 
so, as the cervix is drawn forward, the fundus is lightly pressed 
upon by means of the repositor shown in the cut, and thus forced 



296 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

into place. A firm cotton tampon is then placed anterior to the 
cervix, and the patient allowed to assume a recumbent position ; as 
she does so the intestines fall back into their normal position, and 
with the intra-abdominal pressure aid very materially in keeping 
the uterus forward. 

Adherent Retropositions. — Tubal disease being excluded, as well 
as other pus-foci in the pelvis, reposition of the adherent organ 
may be attempted under rare circumstances only. Even here we 
cannot recommend the procedure. This necessitates divulsion of 
the adhesions under narcosis or their separation by gradual mas- 
sage. The patient being placed under ether, the finger is passed 
into the rectum and the uterus pulled forward. The free hand on 
the abdomen is depressed deeply along the sacral curve until its fin- 
gers touch those in the rectum. The control of the body of uterus is 
now given into the abdominal hand and the finger withdrawn from 
the rectum. With nail-brush and 2 per cent, lysol solution an 
assistant or nurse cleanses the hand. Two fingers are then intro- 
duced into the vagina, and the corpus uteri pushed upward and 
forward while the abdominal hand follows down between the rec- 
tum and the fundus. Thus may any adhesions between the two 
be ruptured. The rest of the maneuvre is completed as before, 
and a large vaginal tampon of sterilized lamb's wool is introduced. 
Hemorrhage necessarily follows from rupture of these adhesions, 
but it is not severe. More or less pain is produced, and some 
peritonitis may result. 

By the gradual or Brandt's method the attempts at replace- 
ment are not violent, but made every other day or every third day 
until the stretching and gentle breaking accomplishes a replace- 
ment ; each maneuvre should be followed by a snug vaginal tampon 
of ichthyol-glycerin in order to sustain the gain made. 

Neither method is applicable in very fat women, owing to the 
impossibility of reaching the uterus from above without crowding 
enough tissue into the pelvis to fill it. 

The uterus is best replaced in women who are stout, and in others 
who are unable to relax the abdominal muscles, by putting them 
either in the knee-chest or modified dorsal position, and employ- 
ing combined rectal and abdominal reposition. To prevent the 
organ slipping from control, it may be necessary to hook the 
blunt bullet forceps in the cervix. The patient is put on an undu- 
lating frame and raised to an angle of from thirty to forty degrees. 



DISTORTIONS AND MALPOSITIONS. 



297 



Working as rapidly as possible, the finger is introduced into the 
rectum and the corpus pushed over against the symphysis. The 
hand on the abdomen then engages it there, and the rectal finger 
pushes the body of the uterus upward and backward toward the 
sacrum. The next move is to shove the cervix directly forward 
toward the upper border of the symphysis at the same time that 
the abdominal hand releases the body. Thus is the uterus forced 
into its proper position over the bladder. 

As a matter of fact, no attempt should ever be made to replace 
or otherwise interfere with a uterus which is bound in its displaced 
position by adhesions. It is impossible to determine accurately 
whether or not there is disease in the uterine appendages in many 
eases, and irretrievable damage may unwittingly be done in the 
manipulations. The only safe and intelligent operations for these 
conditions are intra-abdominal. 

Comparatively few retro-displacements exist without some com- 
plicating inflammatory trouble, either intra-uterine or intra-abdom- 



FiG. 216. 




Diagnosis and Reduction of Retroflexion by the Sound. 

inal, and the symptoms usually arise from the complications and not 
from the displacement. It is all the more necessary, therefore, to 
be on one's guard in selecting proper cases for this treatment. 

Heplacement with the sound is accomplished by curving the instru- 



298 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

ment so that it may be introduced, and then causing the instru- 
ment to make a half sweep. The whole weight of the organ falls 
on the point of the sound, which lacerates the endometrium, and 
has in innumerable cases perforated the uterus. In this maneuvre 
the organ is not raised as a whole, but the fundus is merely forced 
into a different relationship to the cervix. If there be any adhesion 
or other restraint to the raising of the organ, the risk of perforation 
becomes very great, for there is no escape from whatever force may 
be used. 

The method we advocate and practise in all cases where manip- 
ulation and other methods fail — and only when they do fail after 
repeated trials — is as follows : The vagina should be carefully 
cleansed, as also should the cervical canal. The patient being on 
the back, the bladder and bowels empty, the repositor, previously 
sterilized, is introduced very gently into the vagina and locked ; the 
point is made to enter the cervix and engage there, when the instru- 
ment is unlocked. This makes a sound with a joint. The stem 
portion should be only long enough to reach the internal os. Then 
by gentle and careful manipulation the intra-uterine portion is 
coaxed to enter the canal until it has just passed the internal os. 
The proper length has been selected previously and fitted to the hinge. 
The finger of one hand is then pushed high up against the back of 
the fundus, and attempts to lift it are made, at the same time that 
the repositor is pushed downward in the axis of the vagina, toward 
the second sacral vertebra. If there be no adhesions, the uterus 
will become anteverted, and, more, it will be made, cervix and body, 
to assume the normal position in the pelvis ; and this is an import- 
ant property not attaching to the use of the sound. The instru- 
ment is removed, still unlocked, by supporting the cervix Avith one 
finger against it and using the symphysis as a fulcrum to slip the 
staff out of the uterus. If there be intimate adhesions between the 
fundus and rectum, the efforts to replace the organ will merely drag 

Fig. 217. 




Sims-Pryor Uterine Repositor. 



up the bowel for a short distance, and with the finger in the rec- 
tum, the anterior rectal wall will be felt to leave the finger while 



DISTORTIONS AND MALPOSITIONS. 



299 



such efiPort is being made. Or, should the adhesions be of some 
length, the organ will be replaced to a certain extent only, and 
then checked by the false bands. We are perfectly aware that 
there is risk attached to this maneuvre, but with our present 
method of cleansing the operator, vagina, and instrument this is 
reduced to a minimum. We do not consider that any more danger 
attaches to its use than to that of the sound. 

If it be desired to support the uterus by tampons after replacing 
it and removing the repositor, the patient should be in Sims' pos- 
ture. It will then be much easier to replace the organ, as the intro- 
duction of the speculum allows the intestines to gravitate away 
from the uterus. A glance at Waldeyer's plate demonstrates the 
manner in which this reposition takes place. Were the uterus 
retroverted and the bladder entirely empty, elevating it in the axis 

Fig. 218. 



Tntesttnes 



Bladder 



-■/•— Pubes 




Urethra 
Vagina andHifmett 



Girl Aged Thirteen, Frozen Section, showing direction of intra-abdominal pressure ; relations of uterus 
before puberty ; and great strength of pubic segment of pelvic floor. 

of the vagina to a point near the sacral promontory would inevitably 
result in the fundus being dragged forward by the bladder and 
associated tissues. 

This could all be accomplished with the finger against the cer- 
vix were the finger long enough. The stem is merely for the pur- 



300 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



pose of affording a hold on the cervix. By observing even the 
ordinary rules governing all intra-uterine manipulations there is 
not much danger attending the use of this instrument. It elevates 
and replaces the uterus merely by following back the path in which 
the displacement came. It takes advantage of the anatomy, and 
does not act against it. The weight of the organ is borne on the 
whole length of the stem in the cervix, and not on one point, as in 

Fig. 219. 




Waldeyer's Frozen Section of the Female Pelvis ; u, uterus ; B, bladder. 



the use of the sound. With it the exact degree of mobility may be 
appreciated. But it is not to be used where there are pathological 
conditions in the adnexa, or septic endometritis, and therefore must 
have a very limited application. Its use as a means of diagnosis of 
pelvic neoplasms cannot be too strongly condemned. It should be 
employed only in those cases of free retroposition, where there is 
no septic focus in the uterus, peritoneum, tubes, or ovaries. This 
cannot be too strongly insisted upon. 

Again, we repeat, this method is to be used only when manipu- 
lation fails or is impossible, but is always to be preferred to the 
reposition by the sound. Both are to be considered only as last 
resorts. 



DISTORTIONS AND MALPOSITIONS. 301 

Treatment of Retroversion and Retroflexion. — The object 
of all treatment must be to have the uterus approach the normal 
in size and character of its walls, and to place the supporting agents 
in a healthy condition. Therefore, if the uterus be retroposed and 
enlarged, it is essential that it be supported in the proper position 
while such means are employed as will reduce its size. After the 
uterus has been replaced in such cases it is kept in position by 
placing in the cul-de-sac a cotton tampon soaked in some depleting 
agent, as boro-glyceride or ichthyol-glycerin, and then introducing 
a tampon of lamb's wool. This latter should be put in lengthwise, 
rolled hard, and turned sideways, so that the ends will rest in the 
obturator foramina in front of the cervix. When the patient 
stands the downward motion of the cervix is retarded and intra- 
abdominal pressure forces the fundus on the bladder. Combined 
with this, intra-uterine applications of tincture of iodine are to be 
used. The uterus being elevated, its circulation is improved ; being 
in proper position, drainage is secured ; and the astringent intra- 
uterine and depleting hot-water vaginal injections tend to a reduc- 
tion in size. It is well to remember that a large percentage of 
cases of retroposition give rise to no symptoms whatever, and are 
found out only upon the supervention of some complication. 

Ichthyol in 25 per cent, solution in glycerin will cause a cast of 
the vaginal mucous membrane to come away in some cases. In 10 
per cent, it is anodyne, actually relieving local pain; is antiseptic, and 
adds to the depleting effect of the boro-glyceride. 

If there be associated with the retroposition septic endometritis, 
or if that membrane be much hypertrophied, the curette is indi- 
cated, and should be the first step in the treatment. 

Having placed the organ in the proper position and condition, if 
there be tears in the pelvic floor they must be repaired. Nothing 
tends to the production of the displacement more than costiveness 
and straining at stool while the woman is still puerperal. There- 
fore in all cases w^here the perineum is torn it is better to give a 
softening enema each day, rather than allow her to strain at 
stool and occasion a rectocele. Certain cases are symptomatically 
relieved upon the establishment of thorough drainage, and com- 
monly the attendant endometritis is cured. 

Artificial supports, as pessaries, are contraindicated until the 
uterus returns into a healthy condition, and all lacerations condu- 
cing to displacement are repaired. When that is done, we will find 



302 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

in most cases that pessaries are not needed. The tampon acts so 
much better in the majority of cases where any such support is 
called for that the pessary is falling more and more into disuse. 
The tampon has none of the dangers attendant upon the use of 
the pessary, and is even more effective. 

Retroversion without enlargement, such as we find in the unmar- 
ried, is exceedingly difficult to treat. Here one of three things 
must be done : either fit a pessary, or perform Alexander's opera- 
tion or hysterorrhaphy. 

If it is decided to jit a pessary, this should be done only after 
the uterus is replaced. It is presumed that the integrity of the 
pelvic floor has been made or is perfect. Therefore the apparent 
vaginal space while patients are on the back is not the actual when 
they are standing. So it is that a pessary which seems to be loose 
while the patient lies down becomes too tight as soon as she 
assumes the upright position, because of the contraction of the 
pelvic muscles to support the organs against the intra-abdom- 
inal pressure. While the pessary is in situ, the finger should 
pass all around it with ease. Pessaries act, not by supporting the 
fundus, but by pushing the cervix up away from the symphysis 
and pelvic floor, thereby enabling the bladder and the weight of 
the intestines to drag forward and retain the fundus. It would be 
unfortunate could a pessary be applied so that it extended up into 
the cul-de-sac higher than the internal os : ulceration of the vagina 
would be inevitable. Fortunately, unless the pessary be excessively 
long, this is impossible of accomplishment. 

The soft rubber ring, or the Smith-Hodge pessary of hard rub- 

FiG. 220. Fig. 221. Fig. 222. 






DAVOL RUBBER CO. 

Smith-Hodge Pessary. Smith-Hodge Pessary. Solid Rubber Ring Pessary. 

ber, are preferable to all others. The Smith-Hodge pessary may be 
softened and bent into any shape by immersion in boiling water. 

If the pessary produces the least pain, it should be removed by 
the patient at once. And it is positively contraindicated where 
there is any disease of the adnexa, septic endometritis, urethritis, 
vaginitis, lacerated perineum, cystitis, adhesions, uterine hyper- 



DISTORTIONS AND MALPOSITIONS. 



303 



trophy, and whenever the uterus bends back over the instrument. 
Not often, then, can pessaries be employed with advantage. 



Fig. 223. 




Introduction of Pessary, first stage. 



Pessaries should be introduced as follows : 

The patient is placed on the back and the uterus replaced. 



It 



Fig. 224. 




Introduction of Pessary, second stage. 



is essential that the bladder and bowel be empty. The cervix is 
held up by one finger in the vagina which also depresses the per- 



304 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



ineum. The index finger of the other hand holds the well-greased 
pessary, the thumb and middle finger steadying it. The broad end 



Fig. 225. 




Introduction of Pessary, third stage. 



of the pessary is introduced with one side under the pubes and 
obliquely, so as not to press upon the urethra. As the advancing 



Fig. 226. 




Introduction of Pessary, fourth stage. 



bar of the pessary passes the vulva the hand holding it is carried 
high in front of the pubes, so that the pessary may be inserted in 



DISTORTIONS AND MALPOSITIONS. 305 

the curve of the pelvic outlet. When it has entered the vagina 
so as to reach the cervix, the supporting finger is removed 
and placed against the bow of the pessary, thus guiding it into 
place behind the cervix. The point of the pessary should not 
press upon the neck of the bladder or the urethra, but it should 
be curved downward, so as to take support from the converging 
pubic rami, thus leaving a space between the arms of the point 
for the urethra. Again, the base should not be so curved as to 
press against the ischial rami below. A fairly good test is to pass 
the finger all around the pessary while the woman is on her back. 
If that may be done, when she stands and the muscles of the 
floor of the pelvis contract, the pessary will be snug enough. 

Pessaries should not cause the least pain, and patients should not 
know that they are wearing them except by the relief of the symp- 
toms. Those pessaries having rings into which the cervix fits are 
objectionable, in that the cervix settles down into the ring so 
snugly as to obstruct the egress to its secretions. 

Stem pessaries with a bow attachment are dangerous affairs, even 
more so than stems alone. 

Pessaries which fasten to belts outside the body are not to be 
used, except in cases of complete prolapse where the patient refuses 
all surgical treatment. Under these circumstances they are often 
of great value. 

Fig. 227. 



Pessary for Complete Prolapse. 

Even in cases temporarily benefited by their use the questions 
must arise : How long can the patient wear one ? Do they ever 
cure, or are they not makeshifts ? In cases in which they appear 
of use, are there not better methods? It is far better for the patient 
to go twice a week to the physician for the introduction of a sup- 

20 



306 



AN AMEBIC AN TEXT-BOOK OF GYNECOLOGY, 



porting tampon of sterilized wool than to wear a pessary, even 
under observation. 

Granted that the uterus has been gotten into a normal con- 
dition and all lacerations of the pelvic floor are properly repaired, 
it is occasionally necessary to use pessaries, but only under the 
physician's eye. Furthermore, every change in the soft parts 
of the pelvis produced by pregnancy and labor can be cor- 
rected. In cases of retroversion not due to labor, cases occur- 
ring in the unmarried, pessaries are of but little use, because they 
cannot support the uterus above the symphysis, owing to the short 
vagina, and to hold them anteverted in the pelvic cavity requires a 
force sufiicient to overcome the entire intra-abdominal pressure. 

Patients who use pessaries should take daily cleansing douches, 
and have the supporter removed once a month, cleansed, and allowed 
to remain out for twenty-four hours before being replaced. 

Alexander's operation which is at times used as a means of 
cure in retrodisplacements undoubtedly is of some benefit, and has 
a certain field of applicability. But it is a question whether that 
operation alone could afford much relief. It is. usually preceded 
and followed by measures which ensure its success, and which 
possibly might have succeeded without the Alexander operation. 
Again, the operation has a small rate of mortality and a too high 
rate of failure. It occupies a position between plastic work, which 
has failed in its purpose, and coeliotomy. 

Schiicking's operation may be mentioned merely to condemn it. 
It consists in introducing a hollow sound into the uterus by which 
the organ is replaced. Then a needle is forced through this instru- 



FiG. 228. 




Needle for the Performance of Schiicking's Operation. 



ment, so as to penetrate the anterior uterine wall and appear at the 
anterior vaginal fornix in front of the cervix. It is threaded and 
the thread drawn through the uterus. This ligature is tied. It is 
a blind piece of work, and the bladder is often wounded. 



DISTORTIONS AND MALPOSITIONS. 



307 



The operation of shortening the round ligaments within the 
abdominal cavity, by doubling them upon themselves or stitching 



Fig. 229. 




Schiicking's Operation for Retrodisplaced Uterus. 

them to the anterior surface of the uterus, is likewise to be con- 
demned as inefficient. 

Where a retroposition persists after every apparent complication 
has been corrected, the best operation to perform is hysteror- 
rhaphy. 

If an operator can perform hysterorrhaphy with little or no 
risk to his patient, he will advocate it for intractable retropositions. 
Should he lose 25 per cent, of his coeliotomies, he will advocate pes- 
saries. It is merely a matter of " point of view." 

The endometritis common in these cases must not be overlooked, 



308 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

as it is the most important factor, next to lacerations of the pelvic 
floor, in the causation of retropositions. Every appreciable lesion 
being corrected, and after vaginal support has been faithfully tried, 
Alexander's operation may be indicated. But in all cases where 
there are adhesions, tubal or ovarian disease, or other intra-abdom- 
inal complications, hysterorrhaphy is to be preferred. With these 
limitations and conditions for each procedure, the gynecic surgeon 
will perform more hysterorrhaphies than Alexander operations, for 
the field of usefulness of the latter is very narrow. 

With an entirely wrong idea of these displacements and the 
manner in which they are produced, operators have devised various 
ingenious but useless methods for their relief. Whatever operation 
be selected for repair of the perineum must elevate the rectocele, 
not pull it down. The posterior vaginal wall must be relaxed, so 
that the uterus may rise. 

Women with retropositions conceive very readily, for the simple 
reason that having acquired, not congenital, displacements, the 
uterine muscle and endometrium, though often inflamed, have not 
undergone pronounced structural changes. They also abort very 
easily. 

Retroversions with adhesions demand separate mention. Brandt's 
method shows that the retroposed organ is adherent to the rectum. 
Careful examination has demonstrated the absence of septic endo- 
metritis, and presumably no disease of the adnexa. The retroposed 
uterus has simply become adherent to the rectum. There are three 
methods of forcibly replacing the organ. Narcosis and an amount 
of bimanual manipulations, even to the extent of dilatation of the 
uterus so as to introduce the finger, has been recommended. After 
all this, ice-bags to the belly and confinement to bed are advised. 

The late Marion Sims replaced the uterus under ether by using 
the repositor to steady the organ and push it up, and placing one 
hand above on the abdomen, stripping the bowel from the posterior 
surface of the uterus. 

These two methods necessitate that the adhesions shall be very 
easily ruptured ; that there shall not be the least disease of the 
tubes — not even occlusion ; that the tubes, also, shall not be ad- 
herent to the pelvic floor ; that there shall not be septic endome- 
tritis ; that there shall not be even the most minute pus-focus in 
the adnexa. If any one deems he has diagnostic skill sufficient 
to determine all this, he may choose one of these methods of 



DISTORTIONS AND MALPOSITIONS. 309 

replacement. The amount of danger lurking in such procedures 
cannot however be estimated. 

Whenever the retroposed uterus is adherent, ventro-fixation of 
the organ is indicated. Rare, indeed, must be the cases of adherent 
uterus without some lesion of the adnexa ; we have never found 

Fig. 230. 




Bladder. 



Retroversion of Slight Degree : Adhesions (a and ft) passing from the fundus and posterior wall to the 



rectum. 



such. This being the case, hysterorrhaphy is indicated, inasmuch 
as by it whatever complication exists can be corrected. In pro- 
posing such a measure to a patient it is well to lay before her the 
small rate of mortality, and she must judge whether her suffering 
warrants the risk. If this be refused, the ichthyol-glycerin with 
supporting tampons, together with hot vaginal injections, reduces 
the suffering and lessens the complications. Women who work and 
cannot afford to be invalids will view these questions from a stand- 
point far different from the wealthy, and demand some form of 
radical treatment. 

Alexander's Operation, — The indications for the operation are 
limited. Granted that the perineum has been repaired and all appa- 
rent lesions of labor corrected, yet the organ persists in a retroposed 
state. There are no adhesions, no endometritis, and no tubal or 
ovarian disease. In other words, all the pelvic organs seem to be in 
a healthy condition, but the uterus maintains a retroposition, which 
still gives rise to symptoms. These, and only these, are the cases 
for Alexander's operation. They must be exceedingly rare, for if 
a retroposed uterus is put into a healthy condition, the pelvic floor 
restored, and the organ supported for some months, its ligaments will 
regain their tone and require no shortening. The great overlooked 
cause of persistent retroposition s is endometritis associated with me- 
tritis. The preparations are as for a coeliotomy. From the pubic 



310 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



spine an incision is made in the direction of the inguinal canal 
for two inches. The external ring is opened without wounding 
its pillars, and the thin layer of fascia over the ring severed to 
the fat beneath, which is pulled out, when by groping with a 
blunt hook the ligament may be found. If not found here, the 
canal may be opened to the internal ring if necessary. Having 
exposed one ligament, it is caught with forceps, the wound pro- 
tected by a dressing, and the other ligament sought for and 

Fig. 231. 



> V 'i I'll"' .''I'lh" 







The Round Ligament and its Topographical Anatomy : A, anterior superior iliac spine ; B, crural hernia; 
C, round ligament of the uterus; D, external oblique muscle ; E, saphena vein; F, falciform process of 
the saphenoTis opening ; G, femoral artery in its sheath ; H, femoral vein in its sheath ; I, sartorius 
muscle : K, internal oblique muscle ; A;, conjoined tendon ; LL, transversalis fascia ; M, epigastric 
artery ; N, peritoneum ; O, anterior crural nerve ; P, hernia within the crural canal ; QQ, femoral 
sheath ; R, Gimbernat's ligament. 

secured. The uterus has previously been replaced, and main- 
tained in its proper position by a high vaginal tamponade of 
iodoform gauze, put in the day before the operation. Keplace- 
ment on the sound at the time of operation is condemned, and to 
replace the organ by traction on the ligaments exposes them to 
the danger of rupture. But immediate replacement may be made 
bimanually at the time of operation. The ligaments are then 
drawn out gently until they become tense. If the inguinal canal 
has been opened, its edges should be carefully closed by catgut, if 



DISTORTIONS AND MALPOSITIONS, 



311 



the wound is to be closed, or by silkworm-gut sutures if the wound 
is to be left open. Two to four sutures should penetrate the 
ligament with the pillars of the ring. The excess of ligament, 
amounting to from two to three inches, is cut off. If the patient 
be spare, the sutures may include all the tissues, but if asepsis 
be imperfect and the woman is fat, it is better to treat the lower 



Fig. 232. 




The Round Ligament and its Topographical Anatomy : G, glands in the neighborhood of Poupart's liga- 
ment; H, glands in the neighborhood of the saphenous opening; I, sartorius muscle seen throiigh its 
fascia ; d, aponeurosis of the external oblique muscle ; C, external portion of the Round Ligament. The 
other letters refer to the same parts as seen in the preceding figure. 



portions of the wound by Pryor's method, leaving the fat open 
to granulate. This should, however, be rarely necessary. In 
this way the ring is firmly closed, and the ends of the ligaments 
become buried in a mass of firm fibrous tissue. If the latter 
be adopted, the suture ends may be cut short and the sutures 
allowed to become buried. The ligament is recognized by its 
rounded shape, pink color, and glistening appearance. It is wise 
not to do too much cutting in the ring, but rather to separate 
the loose tissues by pinch-forceps, thus avoiding the nerves and 
vessels. The wounds are dressed with antiseptic gauze. The 
procedure is the same on both sides. The vaginal tampon is 



312 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

removed two or three days after the operation, and a small one 
again applied. This method of support from below is infinitely 
superior to the use of a pessary, as advised by most authors. There 
is no danger of inguinal hernia, owing to the escape of intra-abdom- 
inal pressure at the perineum. This, together with the gentler avo- 
cations of women, prevents this accident after the inguinal canals 
have been opened. 

Wylie or Baer's Operation. — The abdomen is opened with the 
usual precautions against sepsis. The inner side of the round liga- 

FiG. 233. 




Operation Proposed by Wylie and Baer for Retro-displacement of the Uterus. 

ments are scraped, so as to make their surfaces raw ; then, around 
a fold of each, three silk ligatures are passed, so as to include most 
of the ligament and fold the raw peritoneal surfaces on each other. 
Thus the ligaments are shortened, the folds being external. 

Dudley's Operation. — The round ligaments in this case are 
brought in front of the uterus and attached to its surface by silk 
sutures after the approximated peritoneal surfaces have been de- 

FiG. 234. 




Operation Proposed by Dudley for Uterine Retro-displacement. 

nuded. These operations are open to the objection of approxi- 
mating the cornua of the uterus. Patency of the Fallopian tubes 



DISTOBTIONS AND MALPOSITIONS. 313 

is essential to conception, and they are sharply bent by these pro- 
cedures, as also by Alexander's operation. Polk has described a 
case where his operation was followed by occlusion of the tube, 
and it might easily result from the others. Under any circum- 
stances the results do not justify the procedures. 

Hysterorrhaphy. — The precautions mentioned under Coeliotomy 
are to be taken. Silkworm-gut is the preferable suture material, 
combining the advantage of silk and silver wire, while free from 
their drawbacks, the size known as *' Salmon-gut " being the 
best. The abdomen is opened as low down as possible, the incision 
being small. Trendelenberg's posture is of the greatest help, 
because the moment the abdomen is opened the pelvis becomes 
emptied of viscera, thus eliminating the danger of injury to the 
intestines. When the abdomen is opened, a careful inspection is 
made of the uterus and adnexa, and the exact condition of the pel- 
vic contents determined. Under the combined guidance of eye 
and touch existing adhesions are severed. In the majority of cases 
manipulation with two fingers will suffice to break up the adhesions, 
the palmar face of the fingers being directed in this maneuvre to 
the posterior surface of the uterus, and as progress is made the 
uterus is raised. Old and very firm adhesions may require the 
assistance of the scissors or scalpel, care being taken that the rec- 
tum be not wounded. It is in just these cases, the difficulties of 
which may not be foretold, that Trendelenberg's posture is of espe- 
cial benefit, and the incision need not be longer than is required in 
the horizontal posture. If the operation be attempted in the latter 
posture, the greatest annoyance is felt from the intestines slipping 
in between the fingers, which are thereby subjected to unnecessary 
and even dangerous handling. Hemorrhage due to severing of the 
adhesions is very slight, for they are not very vascular, being little 
more than connective-tissue bundles covered by peritoneum. Should 
the capillary oozing be at all disagreeable and collect in a pool in 
the cul-de-sac, a wad of antiseptic gauze, preferably iodoform gauze, 
may be introduced to exercise pressure and catch the blood. This 
is to be removed just before the sutures are tied. Very seldom 
will a ligature or stitch be necessary to control the trifling bleed- 
ing. Should such be required, it may preferably be of catgut. 

The greater the difficulties met with in this operation, the more 
apparent becomes the benefits of Trendelenberg's posture, each com- 
plication contributing a forceful argument in its favor. 



314 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



The uterus bein^ freed and elevated, the adnexa are carefully 
inspected, if their exact condition has not already become apparent 
while releasing the uterus. Should they be the seat of disease which 
warrants their removal, that is now done. The uterus is lifted up 
into the wound and into what is deemed the proper relationship 
to the vagina and the bladder, and a note made of this relative to 
the incision. The organ being retained in the proper position by 
sterilized gauze on a holder, the exact site for the fixation of the 
uterus is determined, and a suture is passed through the entire 
abdominal wall of one side. The needle is again grasped in the 
needle-holder and passed deep beneath the uterine serosa from side 
to side, being entered at the apex of the fundus and penetrating the 
muscular tissue to the depth of one-eighth of an inch. In this way 
the suture lies under about a half inch of the serosa transversely. 
Again the needle is taken and passed through the abdominal layers 
of the other side, opposite the point of first introduction. A second 
suture is introduced in a similar manner about a quarter of an inch 

Fjg. 235. 




Sutures in Position in Hysterorrhaphy. 



posterior to the first one, and passing the uterine serosa, as in the 
first instance. A bayonet-pointed needle is best used, one without 
a cutting edge. Unless a sharp needle be used or too much tissue 



DISTORTIONS AND MALPOSITIONS. 



315 



be taken up by it, the needle-punctures bleed but little. These two 
sutures are held by catch-forceps, and others introduced to close the 
rest of the wound. Two sutures only pass through the uterine 
tissue. The uterine sutures are tied first, after which, if it be 
thought desirable, the patient may be lowered from Trendelenberg's 
posture, all danger of including gut between the uterus and parietes 
having passed when the sutures are tied. While tying the sutures, 



Fig. 236. 




stitches in situ in the Abdominal Wall after Hysterorrhaphy. Two lower sutures— the ones which 

pass into uterine tissue— are shotted. 

especially those which pass through the uterus, the peritoneum of 
the incision should be carefully approximated, and it is wise to leave 
the uterine sutures quite long for identification. It is advisable to 
gently scarify that part of the uterine surface w^hich is to come next 
to the parietal peritoneum, in order to ensure sufficient plastic union 
between the opposed surfaces, but it is not absolutely necessary. 
If the uterus be fastened too near the umbilicus, undue dragging 
will take place on the sutures and increase the tendency which the 
organ naturally has to break away. And if fastened too far for- 
ward, it will embarrass the bladder by making a band across its 
area of distension from the cul-de-sac to a point above the sym- 



316 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

physis. The sutures should be removed about the eighth day, but 
those through the uterus may remaiu three weeks Okr longer. Just 
before their removal the uterus should be held up by an iodoform 
gauze tampon, and vaginal support by gauze or wool should be 
employed for several weeks longer. Pessaries are inadvisable, for 
the reason that this operation is seldom done for uncomplicated 
retropositions. The objections made to the operation are — its pos- 
sible rate of mo.rtality ; the production of a break in the ventral 
wall, with the possibility of hernia ; the formation of a false band 
around which intestines may become caught ; fixation of the uterus 
in a false position ; the induced immobility of the organ ; the pos- 
sibility of failure from the operation, and its effect upon a future 
pregnancy. None of these objections are pertinent when the 
hysterorrhaphy is done for retroposition with adhesions or as an 
operation secondary to another, such as removal of both adnexa,- 
for instance. But they become forcible when we consider the ope- 
ration as a remedial agent directed to the relief of uncomplicated 
retropositions of the organ. They may be considered separately. 
There is no rate of mortality inherent in the operation, and it does 
not complicate other operative procedures performed at the same 
time. Still, there is a certain fractional percentage which not even 
the most precise asepsis can overcome, all of which is due to con- 
tingent diseases, " surgical accidents," etc. The possibility of ven- 
tral hernia is undoubtedly attendant upon every operation in which 
the peritoneal cavity is opened. No case, so far as we know, has 
been reported where intestinal obstruction has been due to the 
adhesion between the uterus and ventral wall, but the operation is 
comparatively new, and such may yet occur. Fixation of the organ 
in a false position is immaterial in view of the relief from symp- 
toms produced thereby. The immobility of the uterus is also 
another, but not a serious objection. That the operation occasionally 
fails is undoubtedly true, but if other morbid conditions, especially 
lesions of the pelvic floor, be properly attended to, failure will be 
very exceptional. The union obtained is very tender, and, like 
other adhesions produced from serous surfaces, it is very elastic and 
prone to stretch. This is eminently so in regard to the uterus fixed 
in this position, for it not only has its own weight to bear, but also 
that of the entire pelvic floor when the latter tends to bulge under 
intra-abdominal pressure. Abortion has occurred in uteri so fixed, 
and is due to coexisting morbid conditions rather than to the fix- 



DISTORTIONS AND MALPOSITIONS. 317 

ation ; but it surely does not occur as often as in fixed retroposed 
uteri. Pregnancy which has progressed to full term has been 
reported a number of times. Repeated Csesarean section in the 
same individual demonstrates the trivial influence of fixation upon 
the pregnant uterus. The indications, then, for primary hyster- 
orrhaphy, are, failure after conscientious and skilled effort to keep 
up a retroposed uterus, and adherent retropositions. 

Estimated Value of the Various Procedures for the Relief of Retro- 
positions of the Uterus. — The causes of the displacement should be 
sought for and corrected. Any conditions resulting from the dis- 
placement are then to be cured. This being done, the organ is to be 
replaced, and attempts to retain it there by means of elastic tam- 
pons, as lamb's wool, tried for months ; or a pessary may, less fre- 
quently, be used for this purpose. The uterus is preferably replaced 
by the bimanual method, but the repositor may be used as an 
extreme measure and under all the precautions surrounding an 
operation. If the retroposed organ be adherent, massage should 
be tried a number of times. Failing with this, coeliotomy may 
be done, the adhesions severed, and the uterus fastened up by 
hysterorrhaphy. Alexander's operation is to be performed only 
after every resource has been tried and has failed, except hysteror- 
rhaphy, but it must not be forgotten that Alexander's operation is 
7iot applicable to adherent uteri or where there is any disease of the 
pelvic peritoneum or adnexa. A very insignificant band of adhe- 
sion will suffice to retain the uterus anteposed, when once it has 
been properly replaced. The intra-abdominal pressure is ojDera- 
tive from behind as well as above, and tends to keep the organ in 
its proper position over the bladder : but when once it falls behind 
that viscus, the intra-abdominal pressure is exerted only from above. 
Hence it is that any slight force when properly placed will be suf- 
ficient to retain it properly. The great cause of these retropositions 
is traction from below or pressure from above upon the enlarged 
uterus, before those frail ligaments — the utero-sacral and round — 
have involuted after labor. 

It is our belief that very many Alexander operations are un- 
necessarily done upon women whose uteri could retain their nor- 
mal position, if patience and continuous support from below were 
used until the round ligaments shrink. These ligaments are but 
tender cords, and would fail if much strength were required to hold 
the replaced uterus forward. It has become the habit with some 



318 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

to supplement a coeliotomy by this operation. Hysterorrhaphy or 
almost any other procedure for retaining the uterus is preferable 
under these circumstances. 

Pkolapsus. 

Descent or prolapse of the uterus may be of any degree, from 
that of slight displacement, which accompanies a retroversion, to the 
complete, where the whole organ is below the pelvic outlet. There- 

FiG. 237. 




Varieties of Prolapsus. 

fore any explanation of the amount of descent must be descriptive, 
and the condition cannot be divided into first, second and third 
deo-rees. 

As a very general rule, the condition occurs in women w^ho have 
borne children, but it also occurs in nulliparae. In the two 
classes the affection is essentially different in etiology, pathology, 
and treatment. 

Complete and partial prolapse comes on gradually in most cases, 
but sudden efforts or effects, as lifting, being crushed, or falling from 
a height, may bring it on acutely by rupturing the round, utero- 
sacral, and broad ligaments. 

Pathology of Complete Prolapse. — The vagina is inverted. 
Its posterior wall is prevented from further descent by the sphincter 



DISTORTIONS AND MALPOSITIONS. 



319 



ani. The anterior wall is checked in further descent by its attach- 
ment to the bladder, the latter doing this through its insertion at 
the symphysis. The epithelium of the vagina becomes thick- 



FiG. 238. 




Vertical Mesial Section of Prolapsus Uteri : u, uterus ; B, bladder; V, anterior vaginal wall ; V", posterior 
vaginal wall ; S, pubic bone ; A, posterior peritoneal pouch ; p, anterior peritoneal pouch. 

ened and like cuticle, it may even in old cases have fine hairs. 
Continuous irritation against the thighs and clothing may produce 
local losses of tissue in the shape of irregular ulcers. The urethra 
is also dragged down, and its canal is U-shaped. The uterus 
occupies the pouch of the inverted vagina, and both before and 
behind are culs-de-sac lined with peritoneum. Both are below the 
outlet of the pelvis. Further descent of the uterus is prevented by 
the anterior and posterior vaginal walls, by the utero-sacral liga- 
ments, but still more by the broad ligaments. The round liga- 
ments play but a small part in supporting the organ. 

The cervix is engorged from stasis, and its vaginal portion, being 
the lowest point of the tumor, may be ulcerated. According to the 



320 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



integrity of the external os, there may or may not be ectropion of 
the cervical mucous membrane. The uterine wall and mucosa are 
in the condition of chronic hypertrophic metritis and endometritis, 
both being thickened with the production of new connective-tissue 
elements. There is usually chronic urethritis from retention of the 
urine in the dilated and prolapsed urethra, and there may be chronic 
cystitis. The cul-de-sac between uterus and bladder and the utero- 



FiG. 239. 



^^-^ 




Complete Prolapse of the Uterus : a, cervical canal ; 6,6, superior portion of the vagina, which is now the 
inferior; c,c,c, mucous surface of anterior wall of the vagina; d, urinary meatus; e,e, probe passed 
vertically into the former neck of the bladder, to show the total turning inside out of that organ ; /, 
ulceration of the vaginal mucous membrane. 



rectal pouch may be occupied by intestines ; and the ovaries and 
tubes lie on top of the fundus. Tension on the broad ligaments 
produces obstruction in the ureters, and inflammatory conditions, 
even hydronephrosis, may result. In very old cases marked atrophy 
of the uterus may ensue. 

The condition is essentially that of hernia through the pelvic 
floor. Continuous irritation of the cervix of the prolapsed uterus 
existing for years may even produce epithelioma. Torsion of the 
broad ligaments produces varicocele in the pampiniform plexus. 

Causes. — The starting-point of all cases of prolapse is a break 



DISTORTIONS AND MALPOSITIONS. 



321 



in the pelvic floor, or relaxation of the uterine ligaments, or 
increased weight of the uterus. With any one of these factors 
present an increase in intra-abdominal pressure will produce 
descent of the uterus. Although the ligaments may for a time 
return the organ to its normal position after such effort, yet the 
continuous strain will in time produce the permanent lesion. 

Thus it is that we find the condition following labor, or resulting 
from a neoplasm, or associated with subinvolution and supravaginal 
hypertrophy of the cervix. The latter condition will be separately 
described. 

Tears in the pelvic floor should warn us against too early resump- 

FiG. 240. 




Complete Prolapsus Uteri, showing ulcer; also hypertrophy of the mucous membrane; the cervix or 

OS not seen. 



tion of duty after labor. For involution of the uterus alone is 
not all that is necessary, but the elongated ligaments and generally 
enlarged parturient canal must also shrink, that the organ may 
have proper support. 

Rupture of the perineum more than any one other lesion con- 
duces to prolapse, and in the following way : The parturient woman 
is naturally inclined to constipation from the very nature of her 
weakened condition. In attempting to force out the stool by strain- 



21 



322 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

ing the break in the pelvic floor allows of the escape of a good deal 
of force, and she has to bear down very hard. As she forces the 
stool down, it does not have the resistance of the perineum, which 
would naturally direct it backward through the sphincter. The 
levator ani, which is the muscle opposed in its action to the sphinc- 
ter ani, and which dilates the latter, being torn, the sphincter cannot 
dilate normally, but rather closes more tightly. The stool there- 
fore meets this muscle contracted, and, the pressure still continuing, 
the contents of the bowel bulge out the rectum into the lumen of 
the vagina, thereby producing a rectocele. In doing this the poste- 
rior vaginal wall is drawn down, and it, in turn, pulls on the cervix. 
In front of the uterus is the thick-walled bladder, preventing its 
forward movement : therefore it is pulled backward. This traction, 
together with the steadily-increasing intra-abdominal pressure wdiich 
the woman keeps up to force out the feces, produces both retrover- 
sion and descent. The bowel is emptied, the pressure subsides, and 
the elasticity of the tissues draws up the displaced organs. Frequent 
repetitions of this, together with other acts of her life which in- 
crease this intra-abdominal pressure, gradually bring about the 
condition we describe as prolapse. The rectocele is the first pouch 
of tissue to appear, as a rule. Following upon this rectocele, the 

Fig. 241. 




The arrow shows the direction of force in the case of a normal perineum when straining at stool. The 
thick perineum resists, and the fecal matter is consequently forced in the line of the anus and a nor- 
mal passage secured. 

uterus having descended somewhat, comes the anterior vaginal wall, 
producing a cystocele. In this anterior pouch is contained more or 
less of the bladder. Cystocele occasionally occurs before the recto- 



DISTORTIONS AND MALPOSITIONS. 



323 



cele, but when it does so it is the result of tears of the anterior wall 
during delivery. So great has become the desire in forceps and 



Fig. 242. 




The perineum being ruptured no longer resists the force of straining at stool, but is i)ushed by the 
advancing fecal matter until it begins to protrude from the vulval orifice. The result is constipation 
and progressive formation of a rectocele. 



other difficult deliveries to avoid wounding the perineum that the 
tissues just beneath the symphysis are subjected to much dragging 
force, resulting in tears to one or the other side of the urethra. 



Fig. 243. 




Cystocele and Rectocele. 



324 AN AMEBICAN TEXT-BOOK OF GYNECOLOGY. 

The urethra may even be loosed from its attachments to the sym- 
physis. It is in this way that so great a laxity of attachment of 
the anterior vaginal wall to the bladder and symphysis is produced 
as to cause the appearance of cystocele before rectocele ensues. From 
what has been said the importance of easy evacuation of the bowels 
by enemata without straining, whenever the perineum is torn, 
must be apparent. When the axis of the uterus has become coin- 
cident with that of the vagina the intra-abdominal pressure bears 
directly upon the uterus continuously, in a direction which tends 
to force it out. It must not be forgotten that in its normal posi- 
tion over the bladder, the intra-abdominal pressure is behind the 
uterus as well as above it, and tends to force it forward. In other 
words, it supports the organ. 

When the cystocele has become at all marked, dysuria is pres- 
ent, and considerable effort must be employed to empty the 
bladder. Thus another cause for increasing the cystocele is gen- 
erated. Complete evacuation of the bladder becomes impossible ; 
a little urine is retained and decomposes ; an irritable and inflamed 
condition ensues at the neck of the bladder, followed by ardor urinae. 
Thus it is that, when once the prolapse is accompanied by cystocele 
and rectocele, these conditions become causes for such efforts to 
empty the bowel and bladder as to still further add to the descent. 

The mechanism of the pelvic floor is very simple and easily under- 
stood. The practical difference in the pelvic floor between the male 
and female is the additional break in the latter by the vaginal canal. 
Nature has guarded this very well by surrounding the whole lower 
third of the vagina with the levator ani muscle. In its action this 
muscle, when contracting, closes the vagina, lifts the perineum, and 
pulls apart the fibres of the sphincter ani if the latter be relaxed. 
The combined action of both muscles is to close the pelvic outlet 
entirely. Whenever a nulliparous woman tightens her belly and 
diaphragm, the pelvic muscles contract involuntarily, as in the 
various movements of the body. When such a woman defecates, 
the sphincter relaxes, the levator contracts and closes the vaginal 
cleft, while the rectal is open, thus preventing any marked descent 
of the uterus. There is a very sufiicient correlation between the 
actions of the two muscles. There are other supplementary but 
unimportant perineal muscles. The levator ani is covered by 
a sheet of the pelvic fascia, known as the obturator fascia, which 
gives it great strength. 



DISTORTIONS AND MALPOSITIONS. 



325 



When the fibres of this fascia and muscle are separated, as in 
laceration of the perineum, their ends retract gradually toward 
the ischial rami of either side, producing the " angles " or " sulci '' 



Fig. 244. 



Fig. 245. 





Showing effect of intra-abdominal pressure on 
uterus in anteflexion with intact pelvic 
floor. 



Pelvic Floor broken down, Uterus in retroflex- 
ion. The intra-abdominal pressure now 
increases the displacement and ends finally 
in prolapsus. 



spoken of in articles on perineorrhaphy. The older the case the 
more marked is this retraction. In recent tears it cannot be ob- 
served. As the rectocele comes down it pushes out between these 
separated fibres. 

A w^oman with ruptured perineum on defecating relaxes the 

Fig. 246. 




Illustrating the Formation of a Complete Prolapsus, 



sphincter, but the levator fibres are torn asunder, and their dilat- 
ing action upon the sphincter is gone. She has to strain, and as 



326 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

she does so the vagina can no longer be closed by the levator, but 
the rent allows the intra-abdominal pressure to force the posterior 
vaginal wall out of the vulval orifice, producing a rectocele. In this 
way, and this only, is prolapsus produced. The condition is rightly 
described as a hernia through the pelvic floor. 

The first step in prolapsus is a retroposition of the organ. As 
this increases rectocele supervenes, and in a short time cystocele. 
When the uterus has descended to the vulva, it loses its retroposed 
position through its attachment to the bladder, becomes more erect, 
and is pulled toward the symphysis. On escaping from the body 
it occupies a position in the centre of the sac. After a certain 
amount of descent has taken place retarded venous circulation 
causes the organ to enlarge, and still more contributes to prolapse. 

Symptoms. — In acute prolapse there are the symptoms of great 
shock, signs of internal hemorrhage perhaps, and severe pelvic 
pain. This condition is rarely seen. Examination will readily 
demonstrate the lesion. 

The uterus is found at o-r outside the vulva, covered with the 
anterior or posterior wall of the vagina, according as it was anteverted 
or retroverted before the accident. The parts are livid from venous 
stasis, due to pressure on the thin-walled veins in the tense broad 
ligaments. The patient is usually unable to urinate, owing to dis- 
tortion of the urethral canal and pressure upon it by the displaced 
organ. The bearing-down pain amounts to agony. 

In chronic prolapse, coming on gradually, the first symptoms are 
those of backache, bearing-down or tenesmus, shooting pains from 
rectum to bladder, costiveness, dysuria, pains radiating down the 
thighs, and absolute inability to walk. And yet a complete pro- 
lapse of many years' standing may produce no effect upon the 
woman, she merely complaining of the inconvenience of the mass. 
There may be symptoms of kidney disease from obstruction in 
the ureters, and the peritoneum is often involved in cases, render- 
ing replacement impossible. The erosions which occur produce an 
annoying discharge. The uterine walls are thickened, but the 
endometrium is not markedly changed. Menstruation seems as 
often decreased as increased, due in part, probably, to the fact that 
most cases occur about or after the menopause. Cystitis is not un- 
common, due to incomplete evacuation of the bladder. The cos- 
tiveness, the continual straining at stool, and the use of evacuants 
produce a proctitis, which may lead to the supposition of the exist- 



DISTOBTIONS AND MALPOSITIONS. 327 

ence of rectal disease only. Objectively, a tumor is found pro- 
jecting from the vulva and attached to the margins of the pelvic 
outlet, and more or less pear-shaped, with the base up. At its apex 
is found the os externum, into which the probe readily enters. As 
demonstrating the importance of drainage from the uterus, it may 
be mentioned that these cases, though subjected to much exami- 
nation at many hands and exposed to all sorts of filth, seldom 
present the changes of septic endometritis, so perfect is the escape 
of the discharges. 

If gut be in the posterior cul-de-sac, there may be a tympanitic 
percussion note at the upper border of the tumor behind. 

Usually the tumor may readily be reduced en masse, with the 
production of intestinal gurgling, and as readily comes down again. 
The sound in the urethra follows down the anterior wall of the 
tumor for a distance. With the sound in the bladder and finger 
in the rectum the two meet without the interposition of the uterus, 
and the finger demonstrates that organ in its new position, with the 
broad ligaments as tense lateral suspensory bands. In using the 
sound in the uterus it must not be forgotten that cases of pregnancy 
in the prolapsed uterus are not rare. Even ectopic gestation has 
occurred with complete prolapse. Occasionally the sound will show 
the uterus to be in a retroflexed position in the sac. If the bowels 
have a tendency to inspissate, the patient has great difficulty in 
defecation, the stool coming down to the rectum and remaining there 
through lack of expulsive power in the abdomen. Retention of 
urine in the cystocele produces cystitis and a constant desire to 
urinate. The urine has an ammoniacal odor in such cases. In 
long-standing cases incontinence of urine may come on, the bladder 
remaining partly filled all the time. 

Less descent of the organ than the above description pictures, 
has been by authors divided into two degrees — the first when the 
cervix is above the vulval orifice, and the second degree when it 
appears at or engages in the vulva. They class complete prolapse 
as of the third degree. There is some convenience in this classi- 
fication, but it is entirely arbitrary. In examining these cases of 
lesser prolapse, the patient lying on her back, the uterus recedes 
quite a distance into the pelvis. But by causing her to bear down, 
she can readily cause the rectocele and cystocele to appear. Neo- 
plasms and ascites may cause descent if the pelvic floor be not 
intact. 



328 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Diagnosis. — Inversion, polypus, and infra-vaginal elongation of 
the cervix uteri might be mistaken for prolapse. In inversion there 
is absence of the cervical canal and presence of the two lateral 
openings of the tubes at the base of the tumor. The protruding 
mass is encircled at its highest point by the cervix, presenting the 
same appearance as though the mass were a polypoid tumor pro- 
truding from the cervical canal. A finger in the rectum will reveal 
the fundus uteri absent from its normal position and the cup-shaped 
depression in the intra-pelvic cervix. A polypus hanging from the 
cervix or protruding through the os presents the cervical opening 
above the tumor. The fundus uteri will be found in its normal 
position. 

Strangulation of the prolapse may occur when the vulval orifice 
is small, the organ coming out easily enough, but swelling from 
stasis, so as to endanger its vitality. 

The Prognosis is excellent, both as to relief of the symptoms by 
palliative treatment and as to the result of operative procedures. 

Treatment. — It having been ascertained that by taxis the 
hernia can be reduced, retention in its proper position becomes our 
object. There are two means by which this may be accomplished. 
Certain patients will not submit to operation until every other 
known means has been tried ; and in some very feeble and old 
patients operation is impossible. In employing mechanical sup- 
ports they should be used so as to produce as little irritation as 
possible. They must hold up the displaced organs against not 
only their own weight, but also against the entire intra-abdominal 
pressure. No support should be used while there are ulcerations. 
These latter are best treated by applications of iodine, the displace- 
ment reduced, the vagina filled with iodoform gauze, and a tight 
T-bandage applied ; or, by reducing the displacement, dusting the 
vagina with boracic acid, and packing it with borated cotton. 
Having cured the ulcerations and erosions, choice may be made of 
a means of support. Hard pessaries must take their points d'appui 
from some bony prominence, as the natural curves of the vagina are 
lost and the canal is perfectly straight, incapable of retaining any 
pessary against the force of the intra-abdominal pressure. The 
only pessary which can be of any use whatever is the cup pessary 
supported externally by a belt about the waist, and therefore apt 
to produce pressure-ulcerations. No instrument that has been 
tried has given such satisfaction and so much relief to patients as 



DISTORTIONS AND MALPOSITIONS. 



329 



Braun's colpeurynter. It takes its point of support evenly from all 
parts of the pelvic outlet. Before introduction it should be thor- 
oughly cleansed, the vagina washed with boracic-acid solution, and 
the bag covered by zinc ointment. Being of soft rubber, it has a 



Fig. 247. 




Tamponade of Vagina for Prolapsed Uteri, in the Knee-chest Position. 

tendency to excoriate the moist parts unless greased. In some 
patients the bowel and bladder functions continue with the inflated 
bag in position. This instrument retains the organs in a higher 

Fig. 248. 




Braun's Colpeurynter. 



position than any other. About an ounce of water should be 
introduced into the colpeurynter, and the rest of the distension 
made with air. The water is merely to fill the tube when the 
patient is up and thus prevent the escape of air, with collapse of 



330 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the bag. Or the patient may wear a cup pessary supported by 
a belt around the waist. This should be removed at night and 
the vagina douched with boracic acid. 

The detail of the treatment of these distressing cases is prac- 
tically an enumeration of every known pessary and support, the 
physician in despair putting them aside one by one and hope- 
fully trying another. 

Patients may experiment with hollow rubber balls until one is 
found which will remain in the vagina and keep the uterus within 
the pelvis. They should be removed each night and cleansed, to 
be reintroduced in the morning before rising. 

Posture has a marked effect upon the size of the uterus, and 
before any operation is done the woman should be kept on her 
back wdth the head low, the uterus retained within the body, for 
from ten to fourteen days. During this time also the general func- 
tions may be gotten into good condition. 

Operative procedures devised and tried are about as numerous 
as pessaries. The whole question has now narrowed down to a con- 
sideration of the best means of uniting the levator ani fibres and 
obturator fascia of one side to those of the other, of closing the 
vagina, and holding the uterus upward and forward. 

If the descent be due to polypi or other conditions which render 
the uterus heavy and enlarged, such must be removed by the ope- 
rative procedure appropriate to each. A curettage is of inestimable 
value as a derivative, thus contributing to diminution in the size 
of the organ, whether there be endometritis or not. 

Posteriorly that opei'ation must be applied w^hich pushes up the 
rectocele, narrows the posterior wall, and best approximates the 
separate ends of the levator ani muscle and obturator fascia. 
Operations which drag down the rectocele are to be avoided. The 
preferable one is Emmet's or a high Hegar's colpo-perineorrhaphy, 
the upper part of the denudation being close to the cervix. The 
now fashionable flap-splitting is not thorough enough. Upon 
the anterior wall Emmet's modification of Sims's anterior elytror- 
rhaphy is indicated. LeFort's operation closes the vagina, but, 
inasmuch as the united surfaces are of mucous membrane only, it 
is not as permanent as the combination mentioned above, by means 
of which the vagina can be almost entirely obliterated. Most excel- 
lent results are obtained in the lesser degrees of prolapse by a com- 
bination of Hegar's colpo-perineori-haphy and Stoltz's operation on 



DISTORTIONS AND MALPOSITIONS. 



331 



the anterior wall. Using this latter operation for this purpose, it 
should be done as near the cervix as possible. It then fills in the 



Fig. 249. 




Stoltz's Operation for Cystocele and Hegar's Operation for Rectocele. 

gap left above by the Hegar. If the cervix be hypertrophied, as 
is usual, it should be amputated, or repaired by Emmet's trache- 
lorrhaphy. 

Fig. 250. 




Suture Tied in Stoltz's Operation for Cystocele. Stitches in place ready for Tying in Hegar's 

Operation for Rectocele. 

While in lesser degrees of descent curettage, amputation of the 
cervix, and repair of the pelvic outlet may so reduce the descent as 



332 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

to symptomatically cure the patients, still in the more pronounced 
forms of the lesion no permanent benefit can be expected from those 
procedures only, and they must be supplemented by hysterrorhaphy. 
Alexander's operation fails here utterly. 

Although in exceptional cases all operations may be done at one 
sitting, yet it is better usually to divide the procedures into two, 
doing at first the curettage, amputation of the cervix, anterior 
colporrhaphy, and hysterorrhaphy. The colpo-perineorrhaphy 
requires a separate sitting for its proper performance, especially as 
it is necessary to remove the cervical stitches before those in the 
perineum are placed. 

The whole object of these various operative procedures is to 
reduce the organ in size and at the same time retain it in an elevated 
position. 

Acute prolapse rarely occurs alone, but associated with it are 
other injuries produced by the same violence. It is to be treated 
by gently returning the organ and packing the vagina lightly with 
cotton or gauze. An ice-bag to the suprapubic region will limit 
pain and bleeding. Symptoms of internal bleeding from ruptured 
ligaments should be treated by putting the patient in Trendelenberg's 
posture and by saline transfusion. 

In complete chronic prolapse the following operations must be 
done as a matter of routine : At the first sitting curettage, trachelor- 
rhaphy, Emmet's anterior colporrhaphy, and hysterorrhaphy. In 
three or four weeks afterward either Hegar's colpo-perineorrhaphy 
or Emmet's perineorrhaphy should be done. The time intervening 
between the two operative procedures is occupied with attention to 
the dressings for the curetted uterus and to removal of the sutures. 

Lesser degrees of prolapse, those where the uterus does not 
escape from the body, require the same operative interference except- 
ing the hysterorrhaphy. All the various plastic operations may be 
done at one sitting. The uterus is curetted, the cervix repaired, on 
the posterior wall a high Hegar or Emmet's colpo-perineorrhaphy 
is done, and on the anterior either an Emmet or a Stoltz anterior 
colporrhaphy. When doing these combined operations it is better 
to sew the cervix with catgut. 

In old women, who may not expect conception, the preferable 
procedure is extirpation of the organ instead of the plastic opera- 
tion. The uterus may be removed per vaginam much mord rapidly 
and with less risk to these patients than if tedious plastic work be 



DISTORTIONS AND MALPOSITIONS, 333 

done. The danger to old women lies largely in prolonged etheriza- 
tion necessary to plastic work of this extent. This is not the case 
with the rapid hysterectomy. 

SUPKA VAGINAL HYPERTROPHY OF THE CeRVIX. 

The exact causes of this condition are unknown. It will be 
remembered that in early infancy the cervix alone exists, there 
being no corpus. It is possible that some excitant gives the cervix 
a false start about puberty, and it grows in an entirely dispropor- 
tionate degree. The condition is to be distinguished from the other 
forms of cervical hypertrophy already described. It is charac- 
terized by an inordinate hypertrophy of that portion of the cervix 
which is attached to the bladder. So great is this hypertrophy that 
the increased weight of the uterus causes it to prolapse. The con- 
dition is peculiar to the nuUiparous or primiparous, and is not found 
in women who have borne children. With the exception of acute 
prolapse produced by violence, this is the only form found in 
nulliparous women. The uterus descends because of its great 
weight. As it comes down displacement of the upper part of the 
vagina takes place first, whereas in the prolapse of the multiparous 
the rectocele and cystocele precede the descent of the uterus. When 
the prolapse has become complete, so that the entire vagina is turned 
inside out, yet will a part of the fundus remain within the pelvic 
cavity. The essential pathological condition is one of hypertrophy 
of the cervix above its insertion into the vagina. This is not due 
to inflammatory action, but is rather an excess of normal elements. 
The changes in the vagina and bladder are here the same as in the 
other form of prolapse. Owing to the small size of the vulva the 
tumor is constricted above at first, but in long-standing cases the 
vulval orifice is fully distended. The base of the tumor is above, 
the apex below. The sound in the urethra and finger in the rec- 
tum show that the fundus lies between. The sound in the uterus 
will demonstrate its great length. As the patient lies on her back 
the marked difference in shape between the two kinds of prolapse 
becomes apparent. Here the pelvic floor is intact, and there is no 
true rectocele, no redundant vagina. Consequently there is absence 
of that puffy ending to the mass which is observed in the prolapse 
of multiparse. In prolapse due to cervical hypertrophy the vaginal 
walls leave the cervix at an acute angle. The cervix is not lace- 
rated, but rather conical. 



334 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

Symptoms. — These are the same as those of the other forms of 
prolapse. Reduction is not as easy as in true prolapse, owing to 
the greater amount of uterine tissue relative to the size of the 
vagina, and complete replacement within the body to the length 
of the vagina is not usually possible. Straining does not mate- 
rially increase the displacement, and, conversely, the dorsal decu- 
bitus does not lessen it. The general mobility is less than in true 
prolapse. The physical characteristics are stated above. 

Treatment. — This must remain purely of a surgical nature. 
Palliative measures which afford relief in true prolapse are here 
useless. The cervix must be removed by high amputation, so tliat 
sufficient tissue may be taken away. While the wound is healing 
the uterus must be kept in the pelvis by vaginal tamponade of gauze. 
After the union is firm and the sutures are removed the anterior and 
posterior walls may be narrowed by making on each an oval denu- 
dation. The immediate decrease in size obtained does not represent 
the ultimate decrease, for involution of the organ proceeds some time 
after the operation of amputation, and the uterus continues for some 
time to get lighter and smaller. 

InFKA VAGINAL ELONGATION OF THE CeRVIX UtERI. 

Infravaginal elongation of the neck of the uterus occurs as a 
complication of prolapsed uteri, of lacerations of the cervix, and 
as a congenital condition. The elongation in the first two varieties 
is merely apparent, and will not be considered. 

In prolapsus, as the uterus descends, the vaginal vault folds back 
over the supravaginal portion of the cervix and gives it the appear- 
ance of actual elongation. By placing the patient in the knee-chest 
position the uterus falls back into the pelvic cavity, the uterus and 
vagina assume their natural relations, and the apparent elongation 
of the cervix disappears, showing at once the true condition. 

In lacerations of the cervix one lip is oftentimes partially absorbed 
and everted, giving the cervix the appearance of being elongated. 

Congenital elongation of the cervix is comparatively rare. The 
narrow conical cervix of a non-fully-developed uterus is often mis- 
taken for this condition. Such a cervix is really not elongated, but 
is seemingly so from its peculiarly narrow, tapering shape. 

A true elongation of the cervix is always congenital. It may 
consist of an increase in length from half an inch to a protrusion 



DISTOBTIONS AND MALPOSITIONS. 335 

from the vulvar orifice. Frequently the examining finger comes 
in contact with it immediately on passing into the vagina. 

Fig. 251. 




Elongation of Infravaginal Portion of Cervix. 

The symptomatology consists wholly in sterility, unless the descent 
be sufficient for its protrusion into the vulva, when the presence of 
the tumor will usually be detected. Under these circumstances 
coition would be materially obstructed. The diagnosis is easy. 
It may be mistaken for a prolapse, an inversion, or a polypus. A 
digital examination of the vagina will show the tumor to be contin- 
uous with the true cervix, and in no way different from it. Inspec- 
tion as well as examination by the finger discloses the os. A biman- 
ual examination with the finger in the rectum will reveal the fundus 
uteri in its normal relation and position and the vaginal mass per- 
fectly continuous with it. These points being ascertained, there can 
be no excuse for a mistaken conclusion. 

The treatment consists in a simple amputation of the cervix at 
a point about an inch from the vaginal attachments. A description 
of the operation will be found elsewhere. 

Plastic Opeeations. 

Anterior Colporrhaphy {Emmet). — A point just posterior to the 
urethra is marked, and another in front of the cervix. With tenac- 
ula the lateral walls of the vagina, midway between cervix and mea- 
tus, are brought together. If they can be approached too readily, 
the tenacula should grasp farther out. The object is to catch up the 
sides of the anterior wall at points which may be approximated with- 
out too much strain. These being determined, they are marked. 
The four points thus chosen are united by an oval line, the greatest 



336 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



diameter of which is at the middle of the vagina. But this rule is 
not invariable, and the greatest width may be made where there 
is the most slack. Denudation is made by cutting with scissors. 



Fig. 252. 




Emmet's Anterior Colporrhaphy, stitches in situ : A, urethra ; B, cervix. 

The operation is exceedingly simple and easily performed. The 
sutures are passed from side to side. They are preferably of silk- 
worm-gut, unless a perineorrhaphy be done at the same sitting, 
when they must be of good-sized catgut ; a double row of sutures 
being used, the first row buried by the second. This is the prefer- 
able operation when it is desired merely to narrow the vagina. It 
does not shorten it, and therefore does not make traction on the 
cervix, as does Stoltz's operation. Karely may it be used alone, 
for cystocele seldom occurs alone; but it is a valuable adjunct to 
other procedures adopted for repair of the pelvic floor and reduc- 
tion in calibre of the va2:ina. 

Anterior Colporrhaphy (Stoltz). — The instruments necessary are 
a male sound (curved), about No. 24 French ; two tenacula; mouse- 
tooth forceps ; bullet forceps ; scalpel ; scissors and a half-curved 
Hagedorn needle and needle-holder. The preferable suture mate- 
rial is silkworm-gut. With the tenacula the lateral vaginal walls 
are picked up and approximated toward the centre of the ante- 



DISTORTIONS AND MALPOSITIONS, 337 

rior wall, so as to fix the external points, which may be brought 
together without exercising too much tension. These two points 
are then snipped with the scissors. A point in front of the 
cervix is seized in like manner, and another behind the meatus. 
These two are then brought toward each other, and the proper 
degree of tension in this direction likewise determined. They then 
are marked with scissors. The object is to get four determined 
points which when approximated to a common centre barely miss 
touching, so that when the suture is applied these points may be 
closed in without risk of the suture cutting out. All the mucous 
membrane embraced within these points is now denuded. This is 
best done by using the sound in the bladder as a resistant body 
upon which to cut. The denudation may be made by means of 
eithei' scalpel and forceps or by means of the scissors. The four 
points mentioned are united, not by straight lines, but by curved, so 
that the denuded surface when complete is in the shape almost of a 
circle. The needle is then threaded and entered to one side of the 
centre line, behind the meatus. It appears upon the raw surface, 
and is then introduced on that surface and made to come out on 
the mucous surface. The same maneuvre is repeated until the 
entire circumference of the denudation is surrounded, the needle 
coming out for the last time across the median line from the point 
of entry. The suture skips alternately raw and mucous surfaces, 
each skip being about half an inch in length. The sound is then 
withdrawn from the bladder, and with its point an assistant inverts 
the centre of the raw surface toward the bladder, the operator at the 
same time drawing on the suture. The edges of the denudation are 
thus drawn toward a common centre, and the cystocele made to dis- 
appear into the bladder-cavity. As the urethra is rather stoutly 
attached to the symphysis, this edge of the denudation moves 
inward farther than the one near the cervix uteri, so the latter is drawn 
down toward the urethra. The suture is tied and left long. It really 
is a tobacco-pouch suture. There is no advantage in accurately 
uniting the ragged puckered edges. The suture is cut and drawn 
out in about ten days. The urine should be drawn once in six 
hours. 

As this operation pulls down the cervix, it is contraindicated in 
all eases where a cystocele exists with an antiposed uterus — i. e. in 
cases where the organ descends and yet retains its proper axis. 

But the operation is very useful as part of a combined procedure. 

22 



338 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

It narrows the anterior wall very effectually, but not more so than 
Emmet's anterior colporrhaphy, and the latter does not drag 
the cervix downward. Stoltz's operation is the one of choice for 
cystocele where at the same sitting it is desirable to do a curettage, 
possibly a trachelorrhaphy and a perineorrhaphy. Its only ad- 
vantage over Emmet's anterior colporrhaphy, is that there is but 
one easily accessible suture to remove, and because it produces a 
circular cicatrix which is very firm. It is very easily performed by 
a simple technique. 

Colpo-perineorrhaphy (Hegar). — The object of this operation is 
to unite the separated ends of the levator ani muscle and pelvic 
fascia, to push the rectocele upward, and to narrow the vagina. It, 
as much as any other operation, accomplishes this by a simple pro- 
cedure. Although the surfaces denuded by this method do not 
resemble the freshly-torn perineum, yet it must not be overlooked 
that we deal with torn perinea when they have acquired two ele- 
ments never present in fresh tears — viz. the rectocele and retrac- 
tion of the divided muscular and fascial edges. We carry out this 
indication to such an extent that we have extended the line of denu- 
dation higher than Hegar does. The divergence between the sepa- 
rated fibres of the levator ani and fascia is very apparent upon part- 
ing the labia in old cases, and these lines constitute the two depressed 
lateral angles. These two angles are near together at the vulval 
orifice, but diverge as they enter the vagina, until at the upper 
third they are not apparent at all. Between them is an ele- 
vation of greater or less prominence, which pouts out into the 
vulval orifice upon straining. This is the hernia of the rectum 
covered by the posterior vaginal wall. There are two parts of 
Hegar's operation — that which narrows the vagina, and that which 
approximates the muscular fibres. The former is entirely intra- 
vaginal, the latter partly vaginal and partly perineal. The sutures 
for the former are all intra vaginal ; those for the latter are vaginal 
and perineal. No special instruments are needed for the operation. 
Some operators make the denudation by means of forceps and 
scalpel, while others insert two fingers into the rectum and cut 
against them with scissors. 

At a point corresponding to the former fourchette, and above the 
level of the " angles," the mucous membrane of the vulva is caught 
by forceps and nicked. The same is done on the other side. High 
up on the posterior vaginal wall, above the rectocele curve, a sim- 



DISTORTIONS AND MAIPOSITIONS. 339 

ilar mark is made. This latter is joined to the two former by a 
light linear touch of the scalpel. With forceps the apex of the 
triangle is seized and the flap dissected down, care being exercised 
that the rectum is not entered. It is difficult to rem.ove the entire 
flap without making buttonholes in it. When the dissection has 
extended to the base of the triangle, the flap is cut off, thus form- 
ing a raw surface as pictured. Denudation with the scissors pro- 
ceeds in exactly an opposite way, the point of beginning being 
at the vulva. By this method the vulval margin is caught in for- 
ceps, and from its lower circumference a strip of tissue is removed 
to a point on the opposite side at a level with the first. This 
maneuvre is repeated until the denudation is complete, each suc- 
cessive strip being shorter than the preceding. Removal by the 
scissors is impossible unless the fingers be in the rectum to furnish 
counter-pressure. Consequently, infection by this method is easier 
than when the scalpel is used. Denudation completed, all bleeding 
from arterial branches must be checked by ligature with very fine 
catgut. Unchecked hemorrhage will produce hematomata and 
interfere with union. 

When the tear has extended through the sphincter the procedure 
is identically the same; only the denudation should extend down- 
ward, so as to uncover the edges of the sphincter. When the recto- 
vaginal wall is torn, again the denudation is made in a triangular 
form, the tear in the rectum running through the centre of the 
denudation. In such cases the apex of the denudation must be at 
least a half inch above the upper margin of the tear, even though 
it be next the cervix. If this amount of tissue is not taken, the 
perineal part may close nicely, but leave a recto-vaginal fistula. 

In passing the sutures a Hagedorn needle and holder are best. 
The first sutures passed are those in the vagina. They are of cat- 
gut, but may be of silkworm-gut if subjected to much tension. 
They are entirely buried, and are passed from side to side, one finger 
in the rectum guiding the needle. The continuous suture is inad- 
visable, but interrupted sutures should be used. When the suturing 
has proceeded so far as to bring the last stitch passed through the 
middle of the rectocele — ^. e. about three-quarters of an inch from 
the base of the triangle — the needle is threaded with heavy silk- 
worm-gut. The lowest suture is passed first, the needle entirely 
buried. The caution is necessary not to enter the needle too far 
out on the skin, but it should be just at the edge. Four or five of 



340 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

these perineal sutures are passed, the last or uppermost one extend- 
ing on the rectocele, up to the track of the last catgut suture, 
but not interlocking with it. 

When the fibres of the sphincter ani are torn, the lower margin 
of the denudation should extend above a quarter of an inch on each 
side, below the lines of junction of the anal mucous membrane and 
the cicatricial tissue. In these cases there is always more or less 
rolling out of the sphincter ends, and these lines may be readily 

Fig. 253. 



Profile View of Hegar's Operation of Perineorrhaphy. 

discerned. In such cases the lower two sutures approximate the 
sphincter fibres. 

Where the recto-vaginal septum is torn a continuous suture 
should be passed from the rectum, from above downward to unite 
the lacerated borders. When tied the knot of this suture is at the 
anal margin. All sutures being passed, the next step is to stretch 
the sphincter ani so as to paralyze it entirely. This is not done 
where the recto-vaginal wall or sphincter is torn. The 'suturing 
brings together fascia and . muscle which perhaps for years have 
been separated and from disease have atrophied. Hence such 
approximation is accomplished under great tension, which latter 
pulls against the sphincter ani, tending to separate its fibres. This 
muscle involuntarily contracts against the attempt, and produces a 
great deal of pain. In addition to this indication, stretching allows 
of the more free escape of intestinal gas. After the sutures are 
tied a stout drain of iodoform gauze is introduced into the vagina 
and projects from the vulva. The catgut sutures are tied in three 
knots, the silkworm-gut in two. Both should be cut to leave ends 
half an inch long. Iodoform is dusted on the perineum, and gauze 
placed over the sutures and held in place by borated cotton and a 
T-bandage. The vaginal gauze is removed at the end of forty- 



DISTOBTIONS AND MALPOSITIONS. 341 

eight hours, and a vaginal douche of saturated solution of boracic 
acid given. Another drain is not introduced unless there be special 
indications for it, such as bleeding or sepsis. Twice a day the 
nurse should irrigate the perineal sutures with bichloride solu- 
tion, 1 : 4000. 

The patient should be given vegetable cathartic pills the second 
night, so as to operate on the third day. When she has the stool 
it may be softened by small enemata of saline solution. After this 
first stool others should be had every second day. The sutures are 
removed about the tenth day. If there be much tension, they may 
cut into the flesh. Alternate ones may be removed then on the 
seventh day. Scrupulous cleanliness is imperatively necessary 
throughout the whole after-treatment. The diet should consist 
largely of soups, vegetables, and fruits. Opium is not needed. 
There is no necessity for confining the legs after the patient has 
recovered her senses from the narcosis, and she may be allowed to 
lie on her side. Confinement to bed for at least two weeks is neces- 
sary, and longer if the operation be part of the procedure to correct 
prolapse. 

When the recto-vaginal wall has been torn and repaired, the 
after-treatment is somewhat different. As little disturbance as 
possible of the pelvic floor is here demanded. Therefore these 
patients should have received a most careful preparation as regards 
emptying the entire intestinal tract before the operation. After the 
operation they should receive liquid food only for three days, with 
cooked fruits. The bowels may be gently assisted by enema if they 
tend to move, but if not laxative pills may be given on the third 
night. In these cases, if the bowels are too fluid, particles are apt 
to leak into the wound, and if too hard, the stool may separate the 
united edges of the rectum. Kectal tubes, whether covered by 
gauze or not, are of no use, but rather harmful where there has 
been complete laceration. 

When the Hegar operation is done as part of a combined proce- 
dure — as, for instance, a curettage, trachelorrhaphy, colpo-perine- 
orrhaphy, and anterior colporrhaphy — the uterus is first curetted. 
Next the cervix is sewed up ; then the uterus is again irrigated, 
and packed with gauze. A wad of gauze is placed over the cervix, 
and the denudation for the Hegar operation made. This raw sur- 
face is covered by iodoform gauze while the anterior colporrhaphy 
denudation is made. The sutures are passed first on the anterior 



342 



AN AMERICAN TEXT- BO OK OF GYNECOLOGY. 



wall and then on the posterior. The wad of gauze is removed from 
the vagina, and the sutures of the anterior colporrhaphy and colpo- 
perineorrhaphy tied alternately. It is well in such cases to have a 
drain of gauze the size of the thumb extending through the length 
of the vagina, to keep the two lines of denudation apart and to catch 
discharges. 

Flap-splitting Perineorrhaphy. — The objections to this opera- 
tion are twofold : It in no way narrows the vagina, and it only par- 
tially approximates the levator ani fibres. Its field of usefulness is 
very limited indeed. Practically, it is applicable to those cases in 
which only the superficial and most exterior fibres of the perineum 
are torn. That by means of it the separated sphincter fibres can be 
united is undoubtedly true. But where a tear is so extensive as to 
produce prolapsus the levator ani also is entirely separated. To 
unite the sphincter by flap-splitting is but part of the work indi- 
cated. In no way possible can this operation narrow the vagina, 
abolish a rectocele, or bring together the separated fibres of the pel- 
vic fascia. It should be performed only in the case of a patulous 

Fig. 254. 




Flap-splitting for Incomplete Laceration of the Perineum ; Relaxation of the Vaginal Outlet. 



vulval orifice without rectocele, in the case of either complete or 
incomplete laceration of the perineum. 

The operation is performed with the patient in the dorsal posi- 
tion. The instruments required are a sharp-pointed pair of scis- 



DISTORTIONS AND MALPOSITIONS. 



343 



sors bent on the flat, a handled perineum needle, and a tenaculum. 
Occasionally a pair of hemostatic forceps will be necessary to tem- 
porarily control bleeding. 

For Incomplete Laceration. — The index finger of the left hand 
being introduced into the rectum as a guide, the point of one of the 
blades of the scissors is thrust into the recto-vaginal septum, mid- 
way between the vaginal opening and the anus, to the depth of half 
an inch or more, care being taken that the instrument enters neither 
the vagina nor rectum. From this point the incision is made, first 
to one side and then to the other. The line of the incision is car- 
ried on each side outward and upward along the boundary-line 
between the vaginal mucous membrane and the skin of the labium. 
It is extended up the labium to that point at which it is desired the 
new vaginal floor shall exist; this point is usually that at which 
the lower caruncle (remnant of the hymen) exists, which point, in 
addition, can be located by the existent scar-tissue. The depth of 
the incisions tapers gradually until they reach the highest point 



Fig. 255. 




Flap-splitting for Complete Laceration of the Perineum ; Laceration through the Sphincter Ani Muscle. 

on the labia. When completed the incisions form the elliptical 

figure U. 

For Complete Laceration.— Where the sphincter ani muscle 
is involved in the laceration the method of repair is precisely simi- 
lar, with the addition of two small slits. They are made by cutting 



344 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



down each side of the anus to the ends of the retracted sphincter 
muscle, beginning the cuts at the curve of the original incision. 
Their length and depth are variable, depending upon the position 
of the retracted ends of the sphincter muscle, which must be exposed, 
so that when they are brought together the two ends may unite. 
When completed the incisions present the appearance as shown in 
Fig. 255. 

With the sides of the wound well separated the sutures are passed 
transversely. Beginning at the middle of the opening, the handled 
needle is made to pierce the skin about one-eighth of an inch from 
its cut edge, is carried three-quarters of the way to the bottom of 

Fig. 256. 




Introduction of Suiares in Flap-splitting Operation. 



the wound, where it is made to emerge, and, being reintroduced at a 
point directly opposite the point of emergence, is carried under the 
tissues of the opposite side until it appears on the skin surface at a 
point directly opposite that at which it was first introduced. The 
eye of the needle is now threaded with a silkworm-gut suture and 
the needle withdrawn, dragging with it the end of the suture. Sev- 



DISTORTIONS AND MALPOSITIONS. 345 

eral similar sutures are passed above and below this median one. 
The topmost suture must pass through the vaginal flap as it is held 
up by a tenaculum ; the lower suture, if the laceration be a complete 
one, must include both ends of the retracted sphincter muscle. The 
corresponding ends of the suture being now tied, or, better, shotted, 
the pelvic floor is lifted up toward the pubis by the crowding in 
below of the gluteal tissues. The result forms a very firm and 
substantial support to the vaginal outlet, but in no way has any 
influence on any injury done to the vaginal floor. 

Following this line of operations in young or middle-aged women, 
rarely will it be found necessary to extirpate the uterus. Only where 
hysterorrhaphy has failed or the parietes are so flabby as to render 
that procedure useless may hysterectomy be performed. 

If hysterectomy be decided upon, it must be followed up by exten- 
sive plastic work on the pelvic floor. 

Only after every operation for supporting the organ from below 
has been tried and failed shall the question of its removal be enter- 
tained. In women at, near, or past the menopause hysterectomy 
is to be recommended as more certain of ensuring a cure. If this 
operation be decided upon, the choice will lie between the vaginal 
and abdominal methods. 

Vaginal hysterectomy is recommended as the preferable opera- 
tion. It should be performed with ligatures, and the stumps fast- 
ened into the vaginal opening, so as to draw the vagina upward 
during the process of contraction and repair, and give that organ a 
permanent support from above, which can be obtained in no other 

way. 

Inversion of the Uterus. 

This fortunately rare complaint is most often a complication of 
labor, and, at the same time, very generally fatal. But cases do 
live, and, as the condition results also from neoplasms, such as 
fibroids, they come to gynecologists as cases of chronic inversion. 
As such they will be described. 

That it may occur in the virgin uterus is undoubtedly true, but 
the vast majority of cases result from childbearing. It is neces- 
sary that the cervix be large and patulous, the fundus heavy and 
soft to enable the uterus to turn inside out, for such is, in reality, 
the condition in inversion. Continuous severe hemorrhage marks 
most cases. The patients are anemic, suffer great pain and bearing- 
down in the uterus, and frequently there is a profuse leucorrheal 



346 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



discharge, often purulent. They are very generally incapacitated 
for their work, and as time progresses they become more and more 
disabled by exhaustiono Examination shows a tumor symmetrical, 
firm, and of reddish color, filling the whole or part of the vagina 
as the inversion is partial or complete. Occasionally a fibroid 



Fig. 257. 



t::ii^4dh''i 



"M^Mhk^mMlk 




Inversion of the Uterus : a, mons veneris ; 6, the larg:er labia ; c, c, nymphse : d, clitoris ; e, meatus 
urmarms ; g, anterior border of the external os of the uterus ; h, fi the internal surface of the 
uterus turned outside. 

polyp of greater or less size is attached to the inverted fundus, and 
this has probably been the exciting cause of the displacement. At 
first, in the early stages, the cervix is open and is occupied by a 
loop of intestine, but later it becomes contracted and merely con- 
tains the Fallopian tubes. The condition may also be associated 
with prolapsus, in which case the tumor may protrude from the 
vagina, under which circumstances it is not infrequently mistaken 
for prolapsus uteri. Generally the tumor is retained in the vagina. 



DISTORTIONS AND MALPOSITIONS. 



347 



Inversion having taken place, the cervix contracts, and strangula- 
tion and gangrene of the uterus may result. Cases have been re- 
ported of spontaneous cure by the fundus sloughing away in con- 
sequence of the constriction to its circulation caused by the cervix 
squeezing it tightly ; also by the organ returning to its normal con- 
dition. Atlee reports an interesting case of this kind, where the 
inverted uterus was reduced by persistent and long-continued efforts 
at coition on the part of the husband after all other treatment had 
failed. The woman became pregnant and was delivered of a 
healthy child. The uterus had been inverted for years. Cases 
progress to a fatal issue from shock, due to hemorrhage, and pro- 
gressive asthenia, sepsis, or peritonitis. The usual cause of death 
in the chronic cases is exhaustion from the continuous loss of 
blood. 

The DIAGNOSIS must be made by examination, and is occasion- 
ally very difficult, although usually the condition is readily deter- 
mined by a vaginal exploration. The soft, uniformly enlarged 
mass is felt filling the vagina, the upper end or pedicle of which is 



Fig. 258. 




Complete Inversion- v, vagina; u, c, incised uterus, showing the cavity ; b, border of the inverted por- 
tion • the round ligaments, Fallopian tubes, and the ovarian ligaments are drawn in it ; I r, round 
ligaments ; t, Fallopian tubes ; o, o, ovaries ; h, cervix covered by peritoneum. 

constricted by a ring of tissue, through which it is very evident 
that the mass protrudes. If that condition be made out satisfac- 



348 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

torily, the true lesion can hardly be overlooked. Should there 
be any uncertainty as to the diagnosis, the bladder and rectum 
should be emptied. Examination combined by means of a sound 
in the bladder and a finger in the rectum will demonstrate the 
absence of the body of the uterus from its normal position, and 
the dimple of the inverted cervix will be felt from above. The 
tumor itself is firm, smooth, and the surface bleeds easily. The 
invariable diagnostic signs are the opening of the cervix above, 
which can be reached by the rectum, even though it may not be 
felt through the abdominal wall, and the very small openings of 
the tubes, at the sides of the base of this tumor, together with the 
constricting band of cervix about the pedicle of the tumor as felt 
in the vagina. 

The PROGNOSIS is unfavorable, on account of the constant loss of 
blood, it being only a question of time as to how long the patient 
can stand the drain. 

Treatment. — Chronic inversion is exceedingly difficult to cure. 
Gentle, continuous taxis, at the same time using some force, is the 
preferable method to be first tried. It is made as follows : The 
hand in the vagina grasps the fundus and exercises firm pressure 
upon it. The hand above, on the abdomen, attempts to distend the 
cervix and make counter-pressure, while the fundus is squeezed and 
pushed up. Many failures should not discourage the surgeon, but 
the pressure should be gradual and steady, care being taken not to 
use undue force, as must be the case in all efforts to overcome the 
contraction of unstriped muscular fibre. Peritonitis and death 
have been known to result from rough and too prolonged efforts 
in this direction. If the cervix yields, it yields rather suddenly. 
The attachments of the vagina to the cervix are of aid to the 
manipulations, and the tumor can be pushed up so as to render 
the vagina tense during the maneuvre. The operation is best 
performed with the woman under the influence of an anesthetic. 
Repeated failures after conscientious effort compel us to consider 
continuous elastic pressure, removal of the organ, or, possibly, 
attempt at replacement by Thomas's method. 

Taxis having failed, continuous elastic pressure must be tried. 
The bladder and bowels being empty, the uterus is pushed up if 
prolapsed, and a Braun's colpeurynter, previously soaked in a sat- 
urated solution of boracic acid for several hours, is introduced. 



DISTOBTIONS AND MALPOSITIONS, 349 

This is then injected with tepid water until it fills the pelvis very 
snugly. 

The contents of the colpeurynter are to be gradually increased. 
It should not be left in too long, but once a day should be removed 
for a few hours, the parts and the colpeurynter cleansed, and the 
latter reintroduced. Few cases will resist this method of treatment. 
The object of the treatment is to exercise a continuous pressure, not 
sufficient, however, to obstruct circulation to too great an extent. 
During the treatment the patient should be kept in bed ; indeed, 
the pain produced by the colpeurynter is pretty severe, and would 
of itself confine the woman to bed. Morphia for its relief is indi- 
cated, but should not be pushed too far. 

The only caution to be made is that the physician should not 
become too easily discouraged in his attempts to replace by taxis 
and the colpeurynter. 

It is now twenty-three years since Thomas advocated opening the 
abdomen and dilating the cervix, and in that time the mortality from 
celiotomy has fallen to a very small percentage ; therefore when taxis 
and the colpeurynter have been given repeated tests and have failed, 
Thomas's operation may be tried, although without much prospect 
of success. If replacement cannot be made by Thomas's method 
very promptly, at the same sitting the organ can be removed by 
abdominal hysterectomy in a few minutes. 

Thomas's Operation for Inversion. — Thomas succeeded with one 
case, and lost his second from infection — something which now may 
be prevented. A consideration of the technique of the operation 
and the changes in the uterus give promise that the mortality can 
be kept below 10 per cent., but the proportion of successes is very 
slight. 

The patient is prepared for both a vaginal operation and a 
celiotomy. The special instrument required is Thomas's dilator. 
It might be usefully modified by making the flanges wider, so that 
at the act of dilating pressure upward may be made, thus con- 
tributing to the rolling out of the inversion. The dilating portion 
need not be so long. A short abdominal incision only is necessary, 
merely sufficient to ascertain the condition of the intraperitoneal 
tissues. The abdomen being open, the operator's left hand is intro- 
duced into the vagina and the mass pushed up to the incision. The 
dilator is introduced and the upper part of the constriction dilated 
at the same time. This is an important observation by Thomas — 



350 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

that the reduction takes place in a manner exactly the reverse of 
that in which the inversion occurred. In this way each fraction of 
the constriction is successively dilated, and the inversion is reduced 
in stages beginning with the cervix. The caution is necessary to 
so apply the instrument as not to wound the tubes. Because of the 
possibility of this it might be better to try the fingers arranged into 
a cone before using the dilator. 

Fig. 259. 




Thomas's Operation for Replacement of Inverted Uterus. 

Vaginal amputation is at no time justifiable. If conservative 
methods fail to reduce the deformity, the uterus must be removed 
in toto. Should the abdomen be opened for a trial with Thomas's 
operation, and that fails, as has usually been the case, removal of the 
womb from the abdominal opening is the proper procedure. Should 
it be decided from the first not to try the Thomas method, but 
to remove the displaced organ, vaginal hysterectomy is the proper 
procedure to be adopted. 

To recapitulate, gentle but well-directed efforts at taxis are to be 
first tried, with the patient under an anesthetic. Should this not 
accomplish the object at a single sitting of an hour, or show very 
decided signs of ultimate success, continuous elastic pressure by 
means of the colpeurynter or Aveiing's repositor is to be tried. 
Should this give no promise of success after several days' trial, 
vaginal hysterectomy is the most rational procedure. 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 



The term " malignant " is applied to those affections of the 
female genital organs which progress toward a fatal termination and 
have a tendency to return after removal. They are attended with 
a characteristic rapid involvement of the surrounding tissues and a 
marked general infection, as is evidenced by cachexia, debility, and 
the metastatic involvement of the internal organs. 

At first these diseases are local, and if early recognition be fol- 
lowed by immediate removal, a perfect cure may in many cases be 
expected. After attaining a considerable size and involving the 
inguinal or post-peritoneal lymphatic glands their removal is simply 
palliative. 

The malignant diseases to which the female organs of generation 
are subject are, in the order of their frequency, carcinoma, scirrhous 
and medullary, epithelioma, and sarcoma. Occasionally a mixture 
of carcinoma with sarcoma is observed, and malignant degeneration 
of benign tumors, such as fibroids, occasionally occurs. 

Malignant Diseases of the External Genitals. 

Carcinomatous tumors are frequently observed in women in the 
organs of generation, but malignant tumors of the external genitals 
are more rarely met with. 

The forms of malignant tumors of the external genitals, in the 
order of their frequency, are, epithelioma, scirrhous carcinoma, 
sarcoma, and medullary sarcoma. 

Epithelioma develops usually on the lower part of the inner sur- 
face of the greater labium in the form of small, round, hard nodules 
which project above the level of the mucous membrane and have a 
rough, uneven surface. They are usually of a whitish color, and 
may remain for a long time unnoticed. They grow slowly in their 
incipiency and are painless. Sooner or later the vascular supply to 
the tissues is increased, and the growth becomes more rapid, the 

351 



352 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

superficial epithelial layer is lost, ulceration begins and spreads to 
the surrounding tissues, and the original seat of disease progress- 
ively increases in area. The rounded form of the original nodule 
is preserved for a long time by the even extension of the induration. 
The ulcers are surrounded by hard, raised margins of a bluish-red 
color, covered with rough granulations, and bathed in a purulent 
ichorous secretion with unpleasant odor. The ulcers, later in the 
course of the disease, may become the seat of papillary excrescences 
which at times attain a large size. 

As soon as the purulent sore is formed the induration spreads 
more rapidly, and usually in the direction of the long axis of the 
greater labium, and upon its inner surface. It is exceptional for it 
to extend beyond the myrtiform caruncles or to the abdominal wall. 

In the course of its growth the epithelial cancer usually first 
involves the lesser labium, then the prepuce of the clitoris and the 
clitoris itself. These parts redden, become swollen and indurated, 
and then ulcerate, forming a long indurated ulcer of a dirty-red 
color, with irregular edges, extending from the lower part of the 
greater labium to the mons Veneris. It is rare for the disease to 
spread to the labium of the opposite side. 

The inguinal glands do not become infiltrated until the ulcerated 
sore has existed for a long time. When this occurs the disease 
rapidly attacks the deeper tissues which up to this time have not 
shared in the involvement. The entire labium assumes a dark- 
red color and becomes swollen, hard, and painful. The epithelial 
sore advances to the perineum and the thigh, forming a deep ulcer 
with an irregular surface. One or more of the inguinal glands may 
harden, take on a rapid growth, ulcerate through the skin, and 
form a sore extending deeply into the tissues. 

The ETIOLOGY of epithelioma is but little known. It occurs only 
in the later years of life, and most frequently about the time of the 
menopause. Heredity appears to have no influence in its occurrence. 
While it usually has its seat on one side of the vulva, it has been 
observed primarily on both labia. Blows and falls upon the labia 
have been referred to as causes, but it is difficult to decide what causal 
relations, if any, they hold to the disease. The pruritus which 
always accompanies epithelioma of the vulva, and is most violent 
in the beginning, has been by some authorities considered not a 
symptom of that disease ; they contend that the epithelioma is a 
result of the continuous rubbing and scratching of the parts for the 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 35a 

relief of the pruritus. This theory, however, has gained few con- 
verts, and is most probably not the correct one. 

Epitheliomatous nodules may exist for months without produ- 
cing symptoms other than obstinate pruritus, or materially chang- 
ing their form or size. As soon as ulceration begins the process 
becomes rapid, and usually causes death in two years. There is 
persistent pain, which is not so severe as in other forms of can- 
cer. The patients suffer from insomnia, are wasted, and gradually 
acquire an earthy complexion. The appetite is almost completely 
lost. The secretions from the ulcerated surfaces are not so copious 
or so offensive as those from cancer. Hemorrhages may occur, but- 
are not common. The loss of flesh and strength progresses rapidly, 
and the patients die, usually in about two years, from chronic sep- 
tic infection. 

The TREATMENT of epithelioma of the vulva consists in its early 
excision, including enough healthy surrounding tissue to ensure its 
complete removal. The use of caustics, at any stage of the dis- 
ease, for the removal of the growths, cannot be too emphatically 
denounced as unscientific and untrustworthy, increasing the suffer- 
ings of the patients and giving them no assurance of complete 
removal. The use of caustics is nearly always followed by a quick 
return of the disease, whereas if the growth be early and freely 
excised, before there is involvement of the inguinal lymphatics, 
the chances for a perfect cure are, in some cases, fair. Even where 
glandular enlargement of the inguinal lymphatics is present, excis- 
ion of the growth and removal of the chain of glands will most 
probably prolong the life and will certainly relieve the sufferings 
of the patient. If the infiltration has spread over the perineum 
and on to the thighs, or if the inguinal lymphatics have ulcerated, 
the treatment should be, naturally, palliative. For these advanced 
cases the use of compresses wet with a saturated solution of chlorate 
of potash has been recommended. 

Scirrhous carcinoma, sarcoma, and medullary sai^coma of the vulva 
as primary growths are extremely rare. The point of origin of 
these tumors is usually the greater labium. Scirrhous carcinoma 
has been observed in the clitoris and in the tissues adjoining the 
clitoris. Sarcomatous growths may originate in the nymphse. Me- 
dullary sarcoma has been observed to grow from urethral caruncle. 

The growth usually develops as a deeply-seated nodule, which 
rapidly spreads toward the skin surface. The overlying skin be- 

23 



354 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

comes adherent and ulcerates, forming an irregular, uneven sore, 
secreting a copious purulent, ichorous discharge. It is a disease 
essentially of old age, occurring usually between the sixtieth and 
seventieth years. 

The SYMPTOMS are much more violent than those of epithe- 
lioma. In the early stages there are pruritus, increased vaginal 
secretion, and the mechanical inconveniences of the tumor according 
to its situation. The pricking, tearing carcinomatous pains occur 
early. The purulent ichorous discharges are profuse. Copious, 
weakening hemorrhages frequently occur. The inguinal lymphat- 
ics are early involved. The patients, as a rule, rapidly decline in 
health, and soon die through progressive loss of strength and meta- 
stasis to the internal organs. 

If the case is seen before extensive involvement of the inguinal 
lymphatics has taken place, the growth should be freely excised 
with the knife or removed with the Paquelin cautery. The opera- 
tor should remove all doubtful parts, without fear of a too great 
loss of tissue. Unfortunately, most of these cases come under the 
gynecologist's notice when wide extension of the growth and the 
involvement of the lymphatics render the treatment only palliative 
and symptomatic. These cases then require the use of antiseptic and 
disinfectant washes to correct the fetor of the discharges, alum and 
Monsel's solution to control the hemorrhages, and the plentiful use 
of opium to render the patients' last days as comfortable as possible. 

Carcinoma of the urethra is a very rare disease, and usually sec- 
ondary to cancer of the external genitals or vagina. Carcinoma 
of the bladder rarely involves the urethra. 

The TREATMENT cousists in excision. If removal of the mass is 
not possible, the urethral canal should be kept open by the daily 
passage of the catheter. Should the growth become too extensive 
for this, an artificial vesico- vaginal fistula should be made to provide 
for the escape of the urine. Local cleanliness and anodynes for the 
relief of the pain are to be mainly relied upon when the disease has 
progressed too far for surgical relief. 

Periurethral cancer develops in the form of nodules in the vesti- 
bule of the vulva near the urethral orifice, or in the cellular tissue 
along the sides of the urethra without involving its walls. The 
mouth of the urethra is usually secondarily involved. The nodules 
are at first hard, non-ulcerated, painful upon pressure, and occasion- 
ally the seat of lancinating pain. The pain usually first causes 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 355 

their discovery. At times they are not observed until ulceration 
has occurred and hemorrhage invites search for its cause. The 
nodules rapidly infiltrate the surrounding tissues, filling the whole 
vestibule, following the course of the urethra to the neck of the 
bladder and to the pelvic fascia, and finally extending over the 
symphysis and descending rami of the pubis, and involving all of 
the included tissue. 

The treatment is operation if early seen — palliative if there is 
extensive involvement. 

Malignant Disease of the Vagina. 

The vagina may be the seat of carcinoma, epithelioma, or sar- 
coma. The carcinomatous and epitheliomatous affections are usually 
secondary, while the sarcomatous are principally primary growths. 

Sarcoma of the vagina appears either in the form of a circum- 
scribed rounded tumor growing from the submucous tissue or as a 
diffuse superficial degeneration of the vaginal wall. Tumors of the 
first variety may be readily confounded with fibro-myoma, and the 
second form may be mistaken for carcinoma. The growth may 
occur as a small warty tumor, or as a rounded or oval nodule which 
may reach the size of a goose-egg. The usual seat of sarcoma of 
the vagina is upon the posterior wall. The circumscribed sub- 
mucous sarcomata are usually composed of spindle cells ; they 
ulcerate late in their course, and occasion symptoms analogous to 
those of the fibro-myomatous tumors of the vagina. There is pain, 
especially at night, obstruction of the vaginal canal, and hemorrhage 
after ulceration has taken place. 

The superficial sarcomatous degeneration of the vaginal wall 
occurs as a small tumor, usually upon the posterior wall, which 
slowly increases in size and resists treatment. Finally, it loses its 
mucous covering, and forms an ulcer with elevated edges and covered 
with readily bleeding granulations. Involvement of the inguinal 
glands does not take place until late in the disease. Hemorrhage 
is a prominent symptom, occurring after violent motion or excited 
by coitus or by straining at stool. The entire periphery of the 
vagina may finally become involved. 

The DIAGNOSIS cannot be made with certainty without micro- 
scopic examination of pieces of the growth. A strong presumption 
of the presence of the disease is not, however, difficult to estab- 
lish. 



356 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The PROGNOSIS is more favorable in the circumscribed sarcomata 
than the diffuse, on account of the greater probability of their com- 
plete removal, although it is extremely bad in both. 

The TREATMENT in the circumscribed form is operation if seen 
before ulceration and lymphatic involvement has occurred. 

In this, as well as in the diffuse form, the treatment is identical 
with that of carcinoma, if the disease has progressed beyond removal 
by the knife. 

Carcinoma and Epithelioma of the Vagina. — Secondarily, the 
vagina is frequently invaded by carcinoma and epithelioma ; it is 
rare, however, to find these growths occurring primarily. It may 
be involved by the extension of uterine carcinoma, of carcinoma 
of the rectum, vulva, urethra, least frequently of carcinoma of 
the bladder, and finally, as metastatic nodules following the re- 
moval of a primary cancer. The primary cancer of the vagina 
appears principally in two forms : papillary epithelioma, which is 
most frequent, or diffuse carcinomatous infiltration of the vaginal 
wall. 

The first form appears as a circumscribed sessile growth, most 
frequently situated upon the posterior wall. The second form is a 
carcinomatous infiltration of the vaginal wall, usually circular in 
outline, involving large areas of tissue and occupying the mucous 
membrane and submucous layer. It may be of either the medullary 
or scirrhous type. 

Concerning the etiology very little is known. The cases occur 
with greatest frequency between the ages of thirty-one and forty. 
Young individuals are seldom affected. Traumatic insults — such, 
for instance, as the pressure of badly-fitting pessaries — have been 
urged as causes. But this opinion is unquestionably erroneous. We 
lay stress upon this point, because among the laity, cancer even of 
the womb is so commonly attributed to the irritating pressure of 
pessaries, that the physician is often much hampered in their use by 
the fears of his patient. Primary cancer of the vagina is extremely 
rare. In a large experience but three cases of it have been seen by 
the author. In each case the sore was just behind the cervix, yet 
in not one had a pessary ever been used by the patient. Of course 
to cancer of the womb the pessary can bear no causal relation what- 
ever, because it does not come in contact with that organ at any 
point. 

In the course of carcinoma of the vagina, in all its forms, there 



MALIGNANT DISEASES OF THE FEMALE GENITALIA, 357 

is a rapid progress toward ulcerating degeneration of the tumor, 
while peripherally and upon its base the neighboring tissues are 
invaded. By the advancing destruction of the tumor the cancerous 
ulcer is formed which may readily perforate into the neighboring 
cavities. From the frequent seat of the neoplasm upon the poste- 
rior vaginal wall, recto- vaginal fistula is usually the first to form. 
The further extension in the lymph-channels involves, in sympathy, 
the lymph-glands in the pelvic connective tissue, and, if the growth 
is deeply seated, also the inguinal glands. 

The SYMPTOMS consist principally of hemorrhage, ichorous dis- 
charge, and pain. Occasionally the patient complains of the 
mechanical inconveniences of stenosis and of obstruction of the 
lumen of the vagina, as impediments to sexual intercourse, or the 
disease may first be recognized during labor as obstruction in the 
birth-canal. Lastly, those disturbances arising from the involve- 
ment of the neighboring organs, the rectum and the bladder, may 
be the first clue to the disease. 

The essential and never-failing symptoms are the anomalies of 
secretion — hemorrhage and the watery and ichorous discharge. 
These depend for their prominence upon the form and vasculariza- 
tion of the carcinoma and the stage in which it comes under obser- 
vation. The hemorrhage usually first makes its appearance after 
coitus or after the straining at stool. Death occurs usually after 
spreading of the ulceration from the progressive debility caused by 
the hemorrhages and discharges. It may also occur in very vas- 
cular growths from hemorrhage. Pregnancy may occur in the course 
of vaginal carcinoma, and the growth then forms a serious compli- 
cation in labor. 

The requisites for the diagnosis of vaginal carcinoma are the 
presence of either a firm sessile tumor immovably fixed in the 
tissues, with an ulcerated surface, or an infiltrated ulcer. Serous 
or ichorous discharge is always present, and hemorrhage is easily 
produced by contact. Papillary epithelioma may appear as a cauli- 
flower growth, and is to be distinguished from unusually large 
benign papilloma by the greater tendency to hemorrhage and the 
striking brittleness of its tissue. From sarcoma the differential 
diagnosis is to be made only by the microscope. It is of import- 
ance to determine if the carcinomatous growth be of primary or 
secondary origin. A thorough investigation of the neighboring 
organs and the position of the growth will determine this question. 



358 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

The growth is only to be regarded as a primary vaginal carcinoma 
when rectum, vulva, bladder, and urethral are excluded as points 
of origin, and the portio vaginalis remains uninvolved or is 
attached only externally next to the vaginal growth, and no other 
distant organ is the seat of cancerous disease. The epithelial and 
papillary forms of cancer usually involve the vagina secondarily 
by extension of their growth from the neighboring organs by con- 
tinuity of tissue. Carcinoma developing from infiltrated nodules 
may occur in the vagina by metastasis from distant organs, as can- 
cer of the stomach. 

Unfortunately, in most cases of cancer of the vagina it is impos- 
sible to remove the entire growth. Destruction of the mass has 
been fruitlessly attempted with the sharp curette, the galvano- 
cautery snare, and cauterization with the most varied corrosives. 
Yet under certain circumstances one is forced to employ them. 
When the tumor is so far circumscribed that its total extirpation 
with enough surrounding healthy tissue to ensure its complete 
removal is possible, this is the only procedure. The operator 
should not hesitate from fear of too extensive a wound to remove 
all suspicious tissue. Should the inguinal chain of lymphatics be 
enlarged, they too should be removed. Owing to the elasticity of 
these tissues it is often possible after extensive removal of the 
vaginal substance to unite the edges of the wound by suture. 

Usually the cases come under notice too late for operation. The 
TKEATMENT is then palliative. The hemorrhage and discharge are 
best controlled by the destruction of the cancerous mass by the use 
of the curette, galvano-cautery, or corrosives. Great care must be 
exerted in applying these means that the bladder, rectum, or 
peritoneal cavity is not opened. Vaginal suppositories, contain- 
ing equal parts of pure pepsin and salicylic acid — say, from five to 
ten grains each — have been found useful. Sometimes the dry powder 
is applied directly to the ulcer, and confined there by a tampon of 
cotton. This application is very irritating to the vulva and out- 
lying genitalia, which should therefore be protected by a coat of 
vaseline or of zinc ointment. The hemorrhage may become very 
alarming, and require tamponing of the vagina with gauze wet in 
saturated alum solution or with absorbent cotton that has been 
wet with Monsel's solution and dried. Later in the disease the 
discharges will require suppositories of chloral and tannic acid, or 
douches of peroxide of hydrogen or permanganate of potash, to 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 359 

correct their odor. The pains imperatively demand the use of 
narcotics, and, as in all cases of advanced cancer, these drugs 
should be given in increasing doses according to the effect upon 
the patient. There is no excuse for allowing these doomed women 
to suffer more pain than is necessary, and the physician is not 
doing his whole duty if he neglects to provide his patient with the 
comfort which opium gives. 

Sakcoma of the Womb. 

Primary sarcoma of the uterus occurs anatomically and clinically 
in two forms — fibro-sarcoma, or sarcoma of the uterine parenchyma, 
and diffuse sarcoma, or sarcoma of the uterine mucous membrane. 
Both forms may consist of round or of spindle cells. 

Fig. 260. 




Sarcoma of the Body of the Uterus. 



Fibro-sarcoma forms a more or less firm, occasionally soft, cir- 
cumscribed, rounded tumor growing from the uterine parenchyma 
and resembling the fibroid tiimor. Like these growths it may be 
submucous, subserous, or interstitial. The growth occurs in the 



360 AN AMEBICAN TEXT-BOOK OF GYNECOLOGY. 

form of rounded nodules, of a rich cellular formation, which appear 
to have invaded the original tissue. When submucous or subserous, 
they form sessile tumors projecting into the cavity or upon the sur- 
face of the uterus. As interstitial growths they are imbedded in 
the tissues of the uterus and form thickenings of its wall. The 
isolated sarcomatous tumors are usually composed of round cells. 
The spindle-celled fibro-sarcoma usually occurs in disseminated 
nodules lying in the uterine parenchyma, but it may infiltrate 
equally the whole organ. It is rare for this growth to appear upon 
the cervix. - Often the uterine fibro -sarcomata are the result of 
sarcomatous degeneration of fibro-myxomatous tumors. 

The diffuse sarcomatous tumors grow from the connective tissue 
of the uterine mucous membrane, and are mostly composed of 
small round cells, seldom of spindle cells. They appear as very 
soft knotty or papillary growths upon the mucous membrane. 
They may occur in single areas or infiltrate the whole mucous 
membrane. The growth usually involves the uterine wall, which 
it penetrates, forming a tumor upon the peritoneal surface. Those 
intestines lying near become involved, adhesions are formed to the 
abdominal wall, and the neighboring organs are invaded by the 
disease. The soft round-celled medullary sarcomata may present 
themselves as polypoid growths attached to folds of the mucous 
membrane. They are grayish- white in color, resembling brain- 
matter, rich in blood-supply, and of soft consistency. The surface 
is usually necrotic, uneven, and dotted over with fungus-like masses. 
The necrotic surfaces are covered with dark- brown colored sloughs. 
These growths are closely related to the cancerous degenerations of 
the uterine mucous membrane. The cervical mucous membrane 
seldom appears to be the point of origin of the diffuse sarcoma. 

Concerning the causes of the origin of sarcoma little is known. 
It may occur at any age. We have observed it as early as the 
twentieth year and as late as the seventieth. But undoubtedly 
there is a special predisposition for the development of sarcoma 
at the climacteric period. Fibro-myomata have been observed to 
undergo change into sarcoma in a number of cases. It is a dis- 
ease which especially attacks nulliparae. It has been remarked 
that diffuse sarcoma originates in the interglandular connective 
tissue of the mucous membrane, just as carcinoma of the body of 
the uterus develops from proliferation of the cells in the glandular 
element. 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 361 

As the SYMPTOMS of the two forms of sarcoma differ essentially 
in character, they will be described separately. 

The most prominent symptoms occasioned by the fibro-sarcomata 
are those caused by pressure according to the position and the size 
of the tumor. Pain resembling in character labor-pains, hem- 
orrhages, and watery discharge are the cardinal symptoms. The 
pain may be wholly absent or be but slight. It is occasioned by 
the attempts on the part of the womb to expel the mass, and is 
referred to the dorsal and hypogastric regions. Hemorrhage is 
first recognized as profuse menstruation, and does not change its 
character until a late stage of the disease. The discharge may be 
exceedingly profuse, of a bloody, serous, or watery character, and 
finally with a very unpleasant odor. 

The uterus is much increased in size and the cervical canal is 
tense. The cervical canal may be, however, dilated and patulous, 
permitting the introduction of the finger. The tumor-masses may 
project from the os into the vagina, or with a patulous cervical 
canal the finger may recognize the soft growths in the uterine 
cavity. The tumor may be expelled into the vagina by uterine 
contractions, which may indeed invert the womb. Pieces of the 
mass can be readily broken off by the examining finger before 
sloughing has taken place. 

There is a marked cachexia and rapid loss of flesh and strength, 
and finally death from peritonitis; pyemia, ileus, or metastasis takes 
place, ushered in by extreme anemia. The metastasis is more fre- 
quent in fibro-sarcoma than in the diffuse form, and occurs in the 
lymphatic glands, the lungs, the liver, and the pelvic cellular 
tissue. 

In the diffuse sarcomata there is usually no distinct tumor to be 
recognized externally. The womb is enlarged and fixed. The 
growth may push itself through the os, giving the picture of a 
circumscribed tumor. This projection through the cervical canal 
is not due to expulsive efforts on the part of the womb, as in the 
fibro-sarcoma, and is not attended with labor-like pains, but is due 
to the rapid development of the neoplasm. Pieces of the mass 
readily break off, and are carried away by the discharges. Hem- 
orrhage is seldom absent, and is usually violent. The menstrual 
type is soon lost, and as the disease usually occurs in the climacteric 
period or later, the hemorrhages excite alarm. The hemorrhage 
may be replaced, especially in the beginning of the disease, by 



362 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

a continuous slight bloody discharge. Along with these profuse 
losses of blood is a rich watery or bloody-serous discharge, that 
is present before sloughing of the tumor-mass has taken place, 
and is usually of a disagreeable odor. Sloughing occurs early, 
and with it the discharge takes upon itself the peculiarities of 
the secretion from the gangrenous parts. The pain, very sel- 
dom absent, is often of great violence. It is of a tearing charac- 
ter, and depends for its intensity upon the depth to which the 
sarcomatous infiltration has penetrated. Death occurs, preceded 
by rapid debility and extension of the growth through the uterine 
walls to the neighboring organs and pelvic floor. 

The certain diagnosis of sarcoma of the womb is arrived at only 
by the careful microscopical examination of its structure. The 
examination of small particles contained in the discharges is not 
sufficient to establish an absolute diagnosis. Either pieces of the 
extirpated growth or portions of the tissue removed deeply from 
the tumor by means of the sharp curette should be used. The 
presence of sarcoma or the sarcomatous degeneration of a fibroid 
tumor must be suspected when a fibrous tumor occurs in the climac- 
teric period, or when a small fibrous tumor, formerly occasioning no 
symptoms, at this time or later begins to increase in size or to be 
attended with pain and hemorrhage. The occurrence of hemor- 
rhage in fibroma of the uterus, when menstruation has for a long 
time ceased, should always excite grave suspicion. The hemor- 
rhage in fibro-myomata ceases or lessens when the climacteric is 
passed. The copious bloody-serous discharge is a still more cha- 
racteristic symptom, which, while not always present in fibro-sar- 
coma, never accompanies benign fibrous tumors except when 
sloughing has occurred. A further characteristic symptom of sar- 
coma is the abnormally rapid growth, especially if observed in the 
climacteric years, when fibromata no longer increase in size. This 
is convincing when the growth is soft and accompanied by unusu- 
ally violent pain. The softness of the growth on palpation, per- 
mitting the ready penetration of the finger into the tumor-mass, is, * 
when sloughing fibroid is excluded, decisive for the diagnosis of 
sarcoma. 

When to these symptoms are added an unproportionate loss of 
flesh and strength, cachexia, and anemia, the diagnosis is made with 
ease. The exact diagnosis should always be made after extirpation 
by microscopical examination. 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 363 

The differential diagnosis between diffuse sarcoma and carcinoma 
of the fundus is never easy and may be impossible. From carci- 
noma of the vaginal portion of the womb sarcoma may be easily 
recognized. In the latter disease the sarcomatous mass will be 
found projecting into the vagina througli a healthy cervix, the 
margin of the os being recognized by the finger as a constricting 
band. 

Much more difficult is the recognition of diffuse sarcoma from 
certain benign hypertrophies of the uterine mucous membrane, as 
endometritis fungosa. This affection seldom occurs after the climac- 
teric, as is the case with diffuse sarcoma ; the age of the patient is 
therefore of some help in establishing the differential diagnosis. 
The general condition of the patient is of great importance. In 
fungoid endometritis the patient may be anemic, but never becomes 
cachectic. The bloody-serous discharge is seldom present. The os 
is more or less patulous in diffuse sarcoma, admitting the finger. 
It is closed in endometritis. In sarcoma the uterus is large, and 
tender to pressure ; in endometritis the size is not increased and 
there is no tenderness. The rapidly-proliferating sarcomatous 
growth frequently projects from the os, polyp-like, into the vagina; 
this never occurs in benign hyperplasias of the uterine mucosa. 
The benign hyperplasias always remain superficial growths, never 
involving the uterine substance. Sarcomatous growths belong 
usually to the deeper layers from the beginning, and infiltrate 
rapidly the uterine substance. The polypoid growths of fungoid 
endometritis sometimes grow again after removal, yet the return 
growths differ wholly from the residual growths of sarcoma. 

The microscopical examination of the pieces found in the dis- 
charges often leads to error, as in sarcoma they may long consist 
of healthy tissue, and in simple hypertrophy, of granulation tissue 
resembling small round-cell sarcoma. Errors may be avoided by 
examining several pieces of the growth removed from different 
positions. 

The PROGNOSIS in both forms of sarcoma is hopeless when the 
whole growth cannot be removed by operative measures. These 
growths may progress, slowly or quickly, to death. Compared 
with the carcinomata, the prognosis for cure by complete removal is 
more favorable, as the lymphatic involvement is slower and the 
early recognition more probable. 

The TREATMENT cousists in total hysterectomy when the disease 



364 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



is recognized before involvement of the broad ligaments or of neigh- 
boring tissues has rendered the operation impracticable. Only when 
the removal is no longer possible should the treatment be symptom- 
atic. In the abandoned cases the symptoms may be for a time 
controlled and the life of the patient prolonged by scraping away 
the diseased tissue with a sharp spoon and cauterizing the surface 
of the wound. The cauterization may be performed by the use of 
chromic-acid solution, fuming nitric acid, chloride-of-zinc solution, 
or, better, by the Paquelin thermo-cautery or by the galvano-cau- 
tery porcelain burner heated to a red heat. The further treatment 
is analogous to that of carcinoma — tonics and attention to the bowels, 
whilst opium must be given to relieve pain. 

Cancer of the Cervix. 

Of all women who die from cancer, one-third die from cancer 
of the uterus. The disease is not so common in the negress as in 
her white sister. Uterine cancer occurs most frequently between 




Epithelioma of the Cervix Uteri, showing the well-defined limitation of the disease. 

the ages of thirty and forty years and between fifty and sixty 
years. It has not been observed under seventeen years, one case 
being reported in a girl of that age. The frequency of its occur- 
rence increases from thirty years to the menopause, after which it 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 365 

again decreases. Very many cases, however, have been observed 
after the climacteric period. 

Sexual intercourse, especially if excessive, is probably one of 
the factors in the causation of carcinoma, as is shown by the fre- 
quent occurrence of these neoplasms in married women. Only a 
small percentage of patients suffering from uterine cancer are nul- 
liparae. Deep laceration of the cervix with ectropion of the lips, if 
unheeded, is a very fruitful predisposing cause of cervical cancer. 
It would appear that the constant irritation to which the raw, gran- 
ular everted lips are subjected in locomotion and coition is the dan- 
gerous element. Long-standing cervical catarrh has also, perhaps, 
a causative influence. Finally, the cervix uteri, like most other ostia, 
as the lip, the pylorus, the caecum, and the rectum, is a favorite seat 
for cancer. 

Heredity exerts a considerable influence in its causation. Among 
the higher classes of society carcinoma relatively seldom occurs, 
while among those of the lower grades, who are required to strug- 
gle for the necessities of life, cancer is observed with striking fre- 
quency. In this respect the occurrence of cancer is directly in 
contrast with that of uterine myoma. 

Epithelioma of the cervical mucous membrane may grow from the 
squamous epithelium of the rete Malpighii, from the cylinder epi- 
thelium within the cervix, or from the glandular epithelial cells. 
Cancer of the uterine parenchyma has its origin in connective- 
tissue cells. 

Cancer of the cervix may present itself either as a papillary or 
cauliflower growth, a nodular or parenchymatous growth, or a super- 
ficial or ulcerating disease of the mucous membrane. 

The cauliflower or papillary form grows from the intravaginal 
portion of the cervix, and may be limited to it for a long time. It 
may develop so profusely as to hide the remaining healthy portion 
of the cervix and the os, appearing as a large papillary growth 
filling up the upper portion of the vagina. Finally, the growth 
spreads to the vaginal vault, which it deeply involves, all the tissues 
surrounding the uterus sharing in the infiltration. Extension may 
take place through the cervical canal to the endometrium by con- 
tinuity of tissue, and the body of the womb may become involved. 

The nodular or parenchymatous form of cervical cancer has its 
origin in one or more nodular formations in the cervical mucous 
membrane. Usually they are situated just beneath the membrane. 



366 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

although they may be upon its surface. The nodules soon part 
with their covering of mucous membrane, and form ulcers which 
fuse together and, by extension, involve the fundus of the uterus 
and the vaginal cul-de-sac. The bladder, rectum, and pelvic 
cellular tissues may finally become invaded. 

The superficial or ulcerative form begins as an infiltration of the 
mucous membrane of the cervix. The infiltrated area soon parts 
with its covering of mucous membrane and ulcerates. The ulcer 
progressively involves the deeper tissues, losing its necrotic surface 
as it advances, until finally the whole womb may be converted into 
a crater-like cancerous mass. By extension the peri-uterine tissues 
are invaded, while the vagina may be but little involved. 

To the malignancy of the cervical carcinoma is added increased 
danger from the fact that the beginning, as a rule, is attended by no 
symptoms, and the disease is almost always discovered when it is 
too late for radical treatment. Only in the superficial or ulcerative 
form of cancer is the early stage attended with discharge and occa- 
sional hemorrhages. The other forms of cancer are attended with 
very slight discharge, and, other symptoms being absent, the case 
does not come to seek the advice of the gynecologist until the can- 
cerous sore has already formed. This is attended with a more 
copious discharge and bleeding, which may occur periodically and 
be confounded with metrorrhagia from other causes. If the patient 
has not passed the menopause, the hemorrhages begin as increase 
in the normal menstruation, but later on occur between the periods. 
Frequently the first symptom noticed is hemorrhage following 
coitus. In the scirrhous form of the disease the bleeding may be 
absent, yet it very generally accompanies the disease, and it may be 
very alarming. The most extreme grade of anemia may result from 
the repeated hemorrhages, yet they very rarely are so copious as to 
produce death. 

The first hemorrhage is usually followed by a sanious discharge, 
which may be slight and attract no more attention than the mucous 
discharges preceding it. The discharge may be purely serous and 
devoid of odor. As soon, however, as ulceration has taken place 
the discharges excite suspicion. Their color is at first dark from 
the admixture of fragments of gangrenous tissue, then grayish- 
yellow, green, brown, or black, and of a sickening smell. The pain 
at the beginning is slight or wholly wanting. Violent pain occurs 
when the infiltration has involved the pelvic connective tissue. As 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 367 

a rule, the pain is proportionate in severity to the size and the hard- 
ness of the infiltrated area. The pain is most violent in slightly 
ulcerated carcinomata, or in those ulcerating late, when the hard, 
unyielding proliferations fill the entire pelvic cavity. 

To the true pains of carcinoma, of a pricking, lancinating, or 
burning character, are soon added those of chronic peritonitis occa- 
sioned by the inflammatory adhesions which form as soon as the 
neoplasm has invaded the peritoneum. The cervical canal in its 
involvement may be so narrow as to retain the secretions of the 
uterine cavity. Attempts on the part of the uterus to expel this 
dammed-up secretion excite violent colicky pain. Complete closure 
of the cervix may occur and hematometra or pyometra result, but 
this is very rare. 

The peculiar hardness of the abdominal wall is in a great meas- 
ure occasioned by the pain, and is characteristic of the later stages 
of carcinoma. The muscular tissues are strongly stretched, the 
intestines elevated, and the pelvic walls give to the touch a peculiar 
sense of hard resistance. 

The other symptoms are occasioned by the extension of the dis- 
ease to the neighboring organs. Usually the growth extends to the 
anterior vaginal wall and involves the bladder. As a result of the 
infiltration of the submucous layers of the bladder-wall the mucous 
membrane becomes irritable, and there is pain on micturition with 
vesical tenesmus. It is seldom that there is retention of urine. As 
the growth advances the ureters become compressed or share in the 
involvement; their calibre is narrowed, and hydronephrosis may 
result. Soon the cancerous masses in the bladder- wall ulcerate ; 
the tissues intervening between the bladder and vagina become 
progressively thinner, and finally are perforated. Frequently the 
rectum is also involved. Preceding the involvement of the rec- 
tum there are usually obstinate constipation and rectal catarrh from 
the pressure of the tumor obstructing its calibre. Following the 
rectal involvement is a progressive thinning of the recto-vaginal 
septum by ulceration and perforation, with the production of a 
recto-vaginal fistula. 

The patient may remain in excellent general condition until the 
disease has attained extensive development. Carcinomatous disease 
frequently attacks large and strong women. The nutrition of the 
body then soon begins to fail on account of the continuous drain of 
blood and serum from the diseased cervix, of the accompanying 



368 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

disturbances in the intestinal tract, and of the general degenerative 
effect of the cancerous disease on the blood. Usually there is 
obstinate constipation, although diarrhea may be present. There 
is a progressive loss of appetite, which maj^ amount to an absolute 
disgust for food. Frequently there is vomiting, which may be the 
result of various causes. The stinking odor of the discharges is 
perhaps a decided element, and the uremic poisoning from pressure 
on the ureters has much to do with its production. The pain 
deprives the patient of sleep. Cachexia soon results from the 
frequent loss of blood and the profuse discharges. The legs become 
oedematous. At a later stage diarrhea sets in, and the patients lose 
flesh and strength rapidly. Fortunately for the patients, uremia, 
occurring from the slow occlusion of the ureters toward the close 
of the disease, clouds the intellect. They become more indifferent 
to their condition ; the anxious expression is lost ; the complaints 
of pain are less frequent ; and they lie listless and dull upon their 
beds, without even attempting to change their positions. Gradually 
the cloud darkens, occasionally broken by a lucid interval, until 
death ends their pitiable existence. 

In the majority of cases death takes place from uremic poisoning 
when the ailment is left to run its course and the patient is not 
carried off by intercurrent disease. The ureters are found thick- 
ened, often to the size of the finger, and the pelvis of the kidney 
greatly distended with urine. Purulent peritonitis may occur, and 
hasten the woman's end before the cancerous disease has involved 
the ureters. Exhaustion is of course a large element in the causa- 
tion of death. 

It is difficult to estimate the course of the disease because the 
early stages are not recognized. As a rule, we may say that death 
occurs in from one year to one year and a half after the inception 
of the disease. 

Carcinoma of the cervix is usually of easy diagnosis, from the 
fact that it is, as a rule, fully developed and often far advanced 
when it comes under observation. In the early stages of its devel- 
opment it is difficult of recognition. The cauliflower or papillary 
kind is the easiest to be recognized. Here the quick growth, the 
irregular, knotted, or cauliflower shape, and the rapid disintegra- 
tion serve to make the diagnosis clear. As a rule, all sessile papil- 
lary or villous growths of the cervix are carcinomatous. 

The parenchymatous or nodular form of cervical cancer is more 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 369 

difficult of diagnosis. It is readily confounded with myoma if the 
nodules are situated in the patulous cervical canal or superficially, 
bulging the mucous membrane of the vaginal portion. A myoma, 
however, is of much harder consistency, and it is seated in normal 
tissue, while the softer carcinomatous nodules are surrounded by 
infiltrated and inflamed tissue. On incising the growth the myoma 
cuts with considerable resistance, while the carcinoma is soft like 
marrow. A positive diagnosis at times cannot be made until an 
excised nodule has been examined microscopically. 

The differential diagnosis between superficial or ulcerating car- 
cinoma of the mucous membrane of the cervical canal and long- 
standing cervical catarrh is arrived at with great difficulty. In the 
early stage of this form of carcinoma the appearance is the same 
in both conditions. The folds and markings of the catarrhal 
mucous membrane are perfectly preserved in cancer, though the 
submucous layers be involved, and the evidences of the malignancy 
only appear when ulceration has occurred. 

Severe long-standing cervical catarrhs, with thickening of the 
vaginal portion and nodular enlargements of the surface, frequently 
excite suspicion of cancer. On close examination it will be found 
that the nodules consist of closed follicles filled w^ith mucus and the 
surface is covered with epithelium. The absence of ulceration 
indicates the benign character of these cases of advanced hyper- 
trophy of the cervix. Should the cervix be eroded, the diagnosis 
may be made by the character of the denuded surface. In cancer 
the margins of the ulcer are sharp and dentated, and the surface 
bleeds readily. The presence of numerous follicles, studding the 
entire cervix or the marginal zone of the ulcer, argues in favor of a 
benign character of the disease. In the digital examination of cases 
of long-standing cervical catarrh, the sensation of an irregularly 
degenerated, hard, carcinomatous growth may be imparted to the 
finger. On examination with the speculum, however, it will be 
noticed that the suspicious points are clothed with epithelium, and 
the absence of ulcers w411 clear the diagnosis. It is well to bear in 
mind that carcinomatous growths are easily broken up by the exam- 
ining finger, while chronic inflammatory changes resist even strong 
pressure. A positive diagnosis should not be given, however, until 
a careful microscopical examination has been made of pieces of the 
growth removed for that purpose. Care should be taken that the 
tissue for examination should not be removed too superficially. 

24 



370 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

When ulceration has taken place the diagnosis is comparatively 
easy, but it must be remembered that carcinomatous nodules of the 
cervix may reach a considerable size before perforating the mucous 
membrane. On the other hand, large ulcerating myomata which 
are protruding from the cervix may so resemble carcinomatous 
growths as to excite grave suspicion. Diphtheritic inflammatory 
deposits upon the cervical portion and neighboring parts of the 
vagina may so closely resemble carcinoma, through the uniform 
swelling and ichorous discharge mixed with blood, as to make the 
diagnosis of carcinoma doubtful. 

It is often difficult to determine how far carcinomatous infiltra- 
tion has extended. The neoplasm often involves the pelvic connec- 
tive tissue much deeper than it appears upon examination. The 
extension of the growth is best determined by combined examina- 
tion through the rectum under ether narcosis. The mobility of the 
womb will also give valuable information on this point, for if that 
organ is firmly fixed the presumption is that the disease has invaded 
the peri-uterine tissues. By catching hold of the cervix with a 
tenaculum, and by dragging the womb down, much information 
can be obtained through the rectum as to the condition of the broad 
ligaments. 

Unfortunately, the patients suffering with carcinoma of the 
cervix come under observation so late in its course that the total 
removal of the growth is usually rendered impracticable by the 
extensive involvement of the neighboring tissues. The condition 
of the patient is then most unfortunate. There is almost unbear- 
able pain, insomnia, progressive loss of flesh and strength, and foul 
odor from the discharges. This condition may be long protracted, 
or death from peritonitis or from some intercurrent disease may 
relieve the patient from her sufferings. The only favorable prog- 
nosis is afforded by the earliest possible operation, when the disease 
is yet limited to the cervix and the whole womb can be removed. 

The TREATMENT of carcinoma of the cervix is either radical or 
palliative. The radical treatment comprises the extirpation either 
of the whole womb or of the diseased portion of the cervix, with 
enough surrounding healthy tissue to ensure its complete removal. 
The former method is, in our opinion, always to be preferred to the 
removal merely of the cervix, because it unquestionably is the more 
thorough of the two operations, and because we never can tell 
whether the cancer is limited to the cervix or has extended to the 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 371 

corpus. The palliative treatment is directed only toward relieving 
the distressing symptoms when hope of removal of the growth has 
been abandoned. 

Amputation of the diseased cervix may be performed by the 
knife, ecraseur, galvano-cautery, or Paquelin cautery, and may be 
partial or complete. Operations performed by the knife are to be 
preferred, on account of the easier surgical manipulation and the 
more rapid healing of the wounds after suture than by those follow- 
ing the other methods of removal. 




Simple Amputation of the Cervix, stitches in situ. 



The partial extirpation of the cervix may be performed by two 
methods : either by a simple amputation of that part of the cervix 
projecting into the vagina, or as a modified wedge-shaped excision. 
The simple amputation of the cervix is less desirable than that by 
the wedge-shaped incision, on account of the greater accompanying 
hemorrhage and the greater difficulty in covering the stump. The 
operation is performed as follows : After thoroughly scrubbing the 
external genitalia and vagina with a solution of soft soap, the parts 
are washed in ether, alcohol, and a strong bichloride-of-mercury 
solution, 1 : 1000. The cervix is exposed by a perineal retractor, 
and grasped by a double tenaculum or volsellum forceps. The 
labia are held apart by two other retractors, and the womb is then 



372 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



drawn down as far as the elasticity of tlie uterine ligament will 
permit. The farther this is possible the easier is the operation. 
Great care must be observed in applying traction, however, when 
inflammatory changes coexist in the adnexa. The mucous mem- 
brane is incised by a circular incision, and the cervix severed as far 
as the canal. Before the entire separation it is advisable to place 
one or two stitches in the severed wall, leaving the ends long. 
These control the bleeding and act as tractors after the cervix has 
been completely severed. Tractors are applied by some operators 
before beginning the operation by passing a strong silk thread 

Fig. 263 




Simple Amputation of the Cervix, stitches tied. 



through the cervix above the field of amputation. The womb is 
now held fast by the tractor, the separation completed, and the 
sutures quickly placed, radiating from the cervical canal like the 
spokes of a wheel. The union of the two mucous surfaces over the 
stump is facilitated if the needle be introduced in the cervical mucosa, 
brought out midway between the cervical mucosa and the vaginal 
mucosa, and a2:ain introduced throusfh the vao-inal mucosa. As the 
circumference of the circular edoe of the vasfinal mucous mem- 
brane is much larger than that of the mucous membrane of the 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 373 

cervical canal, and the tissues of the cervix are very hard and 
unyielding, exact coaptation and a smooth line of suture are never 
attained. The vaginal mucosa is always thrown into folds radiating 
from the cervical canal, but good union is ultimately obtained. 

Fig. 264. 




Wedge-shaped Amputation of the Cervix Uteri, sutures in place ready for tying. 

In performing the wedge-shaped amputation, after cleansing the 
vagina and genitalia as in the former operation and exposing the 
cervix, the anterior and posterior lips are seized in the grasp of 

Fig. 265. 




Wedge-shaped Amputation of the Cervix, sutures tied. 



double tenacula and the cervix split up on either side, as high as the 
vaginal vault. An incision is then made in the outer surface of the 
anterior lip of the cervix, from without inward and upward, and 



374 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



from the inner surface of the lip, from within outward. These two 
incisions intersect in the middle of the lip, giving to the excised 
portion the shape of a wedge. The wedge may be made large or 
small acording to the size of the cervix and to its hardness or soft- 
ness, the object being to leave two movable flaps that may be easily 
approximated and sutured. Before proceeding with the excision 
of the second wedge several stitches are placed uniting the flaps just 
made, and they are immediately tied. This is done partly to control 



Fig. 266. 




Profile of the Wedge-shaped Amputation of the Cervix Uteri, sutures in place. 



hemorrhage and partly to use them as tractors. In knotting the 
sutures it is more convenient to begin in the middle of the lip and 
tie toward either end. The posterior lip is now treated in the same 
manner as the anterior one. The lateral wounds are closed by one 
or two stitches. This method may be varied to suit the condition. 

The removal of the cervix with the cold wire of the ecraseur is 
now no longer performed, but amputation with the galvano-cautery 
snare is still practised by some operators who wish to avoid the 
bloodier operation with the knife. The only commending feature 



MALIGNANT DISEASES OF THE FEMALE GENITALIA, 375 

of the procedure is its bloodlessness, through the cooking of the 
tissues and the consequent closure of the vessels before being cut. 
Braun advances the fanciful theorv that the inoculation of the 
fresh wound by carcinoma germs is avoided, and contends that 
through the heat of the wire carcinoma germs remaining in the tis- 
sues of the stump are destroyed. 

The mode of operation is as follows : After the cleansing and the 
disinfection of the genitalia and the vagina, and after the exposure 

Fig. 267. 




Profile of the Wedge-shaped Amputation of the Cervix Uteri, sutures ready to tie. 

of the cervix with the perineal retractor, one or more double tenac- 
ula are fastened in the cervical tissue and the womb is drawn down. 
The loop is applied at the greatest possible distance from the mar- 
gin of the neoplasm, yet not so near to the bladder as to injure it. 
It is then drawn tightly enough to compress the tissues, while the 
current is closed and the wire heated to a glowing heat. By slowly 
constricting the wire loop the cervix is cut evenly through. An 
even charred surface remains, which heals with the formation of 
dense scar-tissue having a strong tendency to contract. The pouch 
of Douglas is frequently opened ; this accident, however, appears to 
be attended with but little danger. 

These operations have been described in order only that atten- 



376 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

tion may be called to the fact that they are operations in which 
confidence cannot be placed, and that are therefore illegitimate 
procedures. In dealing with a disease so terrible as cancer and 
with so marked a tendency to return, the performance of any ope- 
ration short of total extirpation of the cervix or of the womb seems 
unjustifiable. Surely if we accept the belief of scientific gynecolo- 
gists, that cancer in its incipiency is a local disease, and that if early 
enough operated upon and the growth wholly removed there is no 
return, the choice of operation must lie between that of high ampu- 
tation of the cervix and total extirpation of the uterus. Of these 
two procedures, total extirpation of the womb should, in the vast 
majority of cases, be the choice, for the double reason that the result 
is the more sure if the organ be removed entire, as it is in cancer of 
the breast, and that the operation of high amputation is just as dif- 
ficult of performanace and as dangerous to the life of the patient. 

The method of high amputation was originated by Schroeder in 
1878. His technique is as follows : The vagina, vaginal portion, and 
external genitals are cleansed by scrubbing with a solution of soft soap 
and washing in ether, alcohol, and bichloride-of-mercury solution, 
1 : 2000. The instruments required are to be sterilized by boiling 
them for ten minutes or longer in soda solution, and are then placed 
upon a table at a convenient distance from the operator, in the tray 
in which they have been boiled. The buttocks, thighs, and mons 
veneris are guarded by a broad strip of antiseptic gauze having a 
slit corresponding to the vulvar orifice. The cervix is exposed by 
a perineal retractor and the labia held apart by assistants. The 
cervix is then seized in the grasp of a double tenaculum or volsel- 
lum forceps and traction applied, the womb being drawn down as 
far as the elasticity of the uterine ligaments will permit. A circu- 
lar incision is made from one-half to one centimeter beyond the 
margin of the diseased vaginal mucous membrane. There may be 
considerable hemorrhage from the divided vaginal arteries which 
will require the application of hemostats and ligatures. After the 
hemorrhage has been controlled it is easy with the finger to sepa- 
rate the cervix from the tissues front and back, traction being made 
upon the cervix all the while. The connective tissue here contains 
no large vessels and is easily separated. The cervix is then drawn 
strongly to one side, rendering tense the parametric connective tis^ 
sue on the opposite side, which contains the uterine vessels. This 
tense tissue, being easily recognized by the touch, is surrounded by 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 377 

a ligature, as in the operation for total extirpation. The maneuvre 
is best carried out by a half-blunt staphylorrhaphy or aneurism 
needle. After tightly tying the ligature the included tissue is 
divided with scissors between the ligature and the cervix. This 
ligation should inckide the uterine artery. A ligature is similarly 
placed on the opposite side, and the tissues divided between it and 
the cervix. Frequently the tightly-stretched sacro-uterine liga- 
ments interfere with the drawing down of the uterus. They may 
be included in a ligature and severed, when the uterus will readily 
descend. The ligatures should be applied as far from the cervix 
laterally as possible, so that the division of the tissues does not 
occur close to the cervix. The cervix is now transversely separated 
from the body of the uterus anteriorly as far as the cervical canal, 
and a stitch passed through the vaginal wall, the connective tissue, 
and the divided cervical wall, and brouoht out in the cervical canal. 
This, being tightly tied, provides the means for safely holding down 
the stump after complete separation of the cervix. Should there be 
any hemorrhage at this stage, it may be controlled by the applica- 
tion of several similar sutures. The posterior wall of the cervix is 
now cut through, and sutures passed as before around its circumfer- 
ence, uniting the mucous membrane of the vagina to that of the 
womb. As the upper end of the opened vaginal tube is much 
larger than that of the womb, the vaginal mucous membrane is 
thrown into folds by the sutures. On either side are openings in 
which the ligature strands lie ; these require each a stitch to effect 
closure. If the ligatures include the uterine vessels and are tightly 
tied, there should be very little bleeding in this operation. The lower 
segment of the womb may be removed by this method if desired. 
Douglas's cul-de-sac is frequently opened ; the author has opened 
it several times, but this misadventure did not increase the danger 
of the operation. The w^ound in Douglas's pouch should be imme- 
diately closed by a continued suture of fine silk or catgut. The 
vagina is to be carefully cleansed with boiled water and tamponed 
with iodoform gauze. The tampons are removed and renewed, and 
the vagina douched, at intervals of twenty-four hours. In from five 
to eight days the tampons may be discontinued, but the daily douches 
are persisted in. On the tenth or twelfth day the patient may leave 
her bed. The early removal of the stitches is a matter of no im- 
portance, and the longer they remain the easier is their removal. 
Usually they are removed on the eighth day. If catgut be used 



378 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

throughout, there is no need of paying any attention to them 
whatever, as the loop is absorbed and the knot then falls off. 

The steps of the operation are practically a combination of the 
first part in the vaginal hysterectomy with ligature and a simple 
amputation. A glance at the illustrations of these two procedures 
will render the steps clear. 

The high amputation may also be performed by the galvano- 
cautery knife. The method is as follows : After exposing the cer- 
vix with a perineal retractor, and having the labia held apart by 
assistants, the cervix is seized by a double tenaculum or volsellum 
forceps and drawn down. The position of the bladder is deter- 
mined by the introduction of a sound, and the site of th6 amputa- 
tion carefully selected, so as to avoid wounding the bladder or open- 
ing Douglas's pouch. If it be found that the retro-uterine tissues 
are involved and that the peritoneal cavity must be opened to effect 
the excision, the operation should not be abandoned, for the results 
of such operations are said to be attended with little danger. In one 
such case, in which a hole was burnt into Douglas's pouch, no 
febrile movement whatever took place. The cervix should be 
amputated first, however, and afterward the retro-uterine tissues 
should be excised. A slightly curved cautery-knife . electrode is 
applied cold to the point of election, the circuit closed, and a cir- 
cular incision made, the cutting being finished without the removal 
of the knife. Should it be desirable to remove the knife in order 
that the direction of the incision be altered, the current should first 
be broken and the knife allowed to cool, in order to prevent hemor- 
rhage. 

After the circular incision has been made to the depth of about 
one-fourth of an inch the knife should be directed upward and 
inward, firm traction upon the cervix being kept up all the time. 
The remaining stump will be funnel-shaped, and should be gone 
over again and again with a dome-shaped electrode to render the 
baking of the tissues more thorough. 

In cases requiring amputation above the internal os, the cervix 
should be first removed, the stump grasped on either side of the 
cervical canal, and the higher amputation proceeded with in the 
same manner as before. Thus it is possible by successive attempts 
to excise as high as is desired. The ragged edges are finally to be 
trimmed off by the cautery-knife and the cavity tamponed with 
iodoform gauze. The tampon is allowed to remain for forty-eight 



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Removal of Carcinoma of the Uterus by the use of the Galvano-cautery after the method of Byrne. 



MALIGNANT DISEASES OF THE FEMALE GENITALIA, 379 

hours. The after-treatment consists in the use of antiseptic 
douches. 

This operation can be performed more safely with 'the curved 
knife of the Paquelin thermo-cautery, for then the degree of heat 
can be better adjusted to the hemorrhagic character of the tissues. 
For instance, if the tissues are very vascular, a dull-red heat is less 
likely to be followed by hemorrhage than a white heat. 

We once had a terrific secondary hemorrhage follow the use of 
the galvano-cautery wire — a hemorrhage which was controlled with 
the greatest difficulty. From this cause the late Dr. Albert H. 
Smith of Philadelphia lost a patient of high social position several 
days after the amputation of a cancerous cervix. The author assisted 
him in the operation, which was most skilfully performed, and was 
present when the lady died, being summoned by him at the last 
moment. But with the Paquelin cautery we have made many high 
amputations of the cervix, and have not yet met with a secondary 
hemorrhage. 

When the cancer has involved the vagina and the wall of the 
bladder or of the rectum is infiltrated, or when there is found to be 
involvement of the broad ligaments, the inference is legitimate that 
the lymphatics have also become infected, and all radical treatment 
is contraindicated. Unfortunately, the radical treatment applies to 
a very small percentage of the cases met with both in private and 
in hospital practice. The onset of the disease is so insidious that 
early symptoms are overlooked, hemorrhages are referred to the 
^' change of life " or to irregularities of menstruation, and the 
patients present themselves at last for advice, with such extensive 
involvement that a brief respite from suffering and a short pro- 
longation of their lives is all we can offer them. Our aim in these 
cases should be to check the wasting discharges and hemorrhages, 
and make the patients as comfortable as possible for the short time 
they have yet to live. The hemorrhages and discharges are best 
controlled through the removal of the ulcerating or vegetating can- 
cerous masses by rapidly breaking them up with the fingers and 
scraping away the diseased tissue with a sharp spoon curette. In 
our opinion, the best curette has a serrated edge. It is of import- 
ance to bear in mind the position of the bladder and rectum in 
cases of extensive involvement, as the infiltrated walls of these 
organs are readily perforated, thus rendering, by rectal or vesical 
incontinence, the condition of the patient more uncomfortable than 



380 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

before interference. After sponging the cavity dry, the raw surface 
is seared with the button-shaped end of the Paquelin cautery heated 
to a dull cherry-red heat, and the wound tamponed with iodoform 
gauze. The dressing should be renewed in forty-eight hours, and 
the vagina douched with bichloride-of-mercury solution, 1 : 4000. 
After such treatment the patients gain rapidly in weight and 
strength. The improvement lasts usually from three to six months. 
In a few cases we have known the respite to last for several years. 

The use of caustics applied on small tampons to the raw surface 
after curetting has* been advised. Nitric acid, chromic acid, 5 per 
cent, solution of bromine, and saturated solution of chloride of 
zinc are the caustics usually employed. After their application 
the vagina should be protected by tampons wet in a saturated 
solution of sodium bicarbonate. In forty-eight hours the tampons 
are to be removed, and the parts dressed with iodoform gauze 
until the slough of the cauterized area separates. This usually 
takes place in from seven to ten days. The use of the Paquelin 
cautery seems, however, to meet every indication and to be attended 
with less discomfort to the patient. 

The fetid discharges are best relieved by douches of perman- 
ganate-of-potash solution, 3 to 6 drachms to the quart, of perox- 
ide-of-hydrogen and chloral solutions, or of suppositories of chloral 
and tannic acid, which on account of their irritant action must be 
used intermittently with the douches. Thymol solutions have also 
been recommended. 

For the hemorrhages, which are seldom fatal, yet always weak- 
ening and alarming, it is best to use douches of very hot water or 
of very hot vinegar. If these fail, the vagina may be tamponed 
with pledgets of cotton wet in a saturated solution of alum. Should 
this fail to control the bleeding, some cotton, which has been soaked 
in Monsel's solution and dried, may be placed upon the cervix and 
secured by a gauze tampon. The use of MonseFs solution is seldom 
required, and should never be resorted to if it is possible to control 
the bleeding by other means. It produces dense coagula which are 
liable to occasion fresh hemorrhage in their subsequent removal, or, 
if allowed to stay, undergo decomposition and add to the patient's 
suffering. 

To prevent erythematous eruptions from the discharges, the 
external genitals should be frequently cleansed with castile soap 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 381 

and warm water, washed with lead-water, and anointed with 
borated vaseline. 

The patients, beside local treatment, require tonics and easily- 
digested food. The bowels are prone to become constipated, and 
require special care. The pain, though modified by local treatment, 
is distressing and demands the use of morphia. The withholding 
of opium from these sufferers is cruel in the extreme, and either 
the administration of some form of the drug by the mouth or the 
hypodermic use of morj)hia in whatever quantities required, is 
demanded in every case. They have but a few months to live ; let 
these months be as comfortable as possible. 

The attention of the profession has lately been called to the use 
of pyoktanin in the treatment of cancer. Methylene blue may be 
administered internally, and also externally to the cancer itself. 
Under its influence it has been claimed that the pains are relieved, 
the cachexia diminished, while the cancerous tissue breaks down 
and is discharged. Cures of advanced cases have been reported. 
The drug may well be tried in cases where the disease is too exten- 
sively developed for radical treatment. We have never ventured to 
administer it internally, but we have applied it externally to the 
ulcer without any benefit whatever; and, to tell the truth, we have 
no more confidence in it than in those obsolete remedies which 
once were so much vaunted — viz. Chian turpentine and condurango. 

CARCmOMA OF THE BoDY OF THE UtERUS. 

Carcinoma of the body of the uterus is less frequent than that 
of the cervix, and a more frequent condition than sarcoma. It is 
more a disease of advanced age than cervical carcinoma, and is 
rarely seen before the menopause. It may occur in nulliparous 
women, and is then usually found in sterile women who have 
passed the climacteric and in old maids. 

The disease originates in the glandular element of the uterine 
raucous membrane, and may present itself as a polypoid degenera- 
tion of the endometrium or as a diffuse infiltration. It rapidly 
invades the deeper tissues, which become necrotic and are thrown 
off. From the rapid destruction of the uterine tissue the womb 
soon becomes converted into a crater-shaped carcinomatous mass. 
Adhesions form to the contiguous organs, and perforation may take 
place into the bladder and intestine or into the peritoneal cavity, 
thus causing rapidly fatal peritonitis. The disease extends into 



382 



AJV AMERICAN TEXT-BOOK OF GYNECOLOGY. 



the tubes and involves the ovaries. Metastatic nodules in other 
more remote organs are frequent. 

Symptoms. — The first symptom is hemorrhage. Later on there 
follows a copious watery discharge which may be purulent and offen- 
sive. The discharge may be bloody-serous in character and desti- 
tute of odor, and both hemorrhage and discharge may be wanting. 
The secretions are more fetid when softened carcinomatous nodules 
become loose in the uterine cavity and are expelled from it with 

Fig. 268. 




Malignant Adenoma of the Uterine Mucous Membrane, beginning glandular epithelioma. 

bearing-down pains. The pain differs widely as a symptom. In 
many cases it is wholly wanting. The pains of carcinoma of the 
uterine body are similar to those accompanying other uterine 
tumors. Lumbar and sacral pains are complained of, and fre- 
quently violent pains in one or both lower extremities. Paroxysms 
of pain, recurring at certain hours of the day, are characteristic of 
carcinoma when present, but do not always accompany the disease. 
They resemble the pains of uterine colic, and are occasioned by the 
abnormal contents of the womb. Attempts of the womb to expel 
its contents occasion especially tormenting pain. Later, when the 
growth involves the serous covering, peritonitic pains are added. 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 383 

On examination the uterus will be found uniformly enlarged. 
Later in the course of the disease metastatic nodules may be recog- 
nized as prominences upon its surface, or adhesions to neighboring 
organs render it no longer capable of being definitely outlined. 



Fig. 269. 




Carcinoma of the Body of the Uterus. 

The enlargement is usually not extensive, and in the earlier stages 
it is barely recognizable. The cervix is occasionally patulous, or 
is readily dilatable by the examining finger, permitting the growth 
to be felt in the uterine cavity and pieces to be removed. It may 
be hollowed out by the invasion of the disease, forming with the 
uterus a large cavity. 

The general health usually fails late in the course of the disease. 
Often extensive disease is found in well-nourished women. Three 
times has the author successfully removed the whole womb for this 
disease in women who were fat, ruddy, and the pictures of perfect 
health. In none of these cases was pain the prominent symptom, 
but repeated and very persistent dribblings of blood. In one case 
only was the hemorrhage even alarming. 



384 ^iV^ AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The DIAGNOSIS of cancer of the body of the uterus often pre- 
sents many difficulties. Where the uterus is regularly enlarged 
and there are no bad-smelling discharges, the case may easily be 
regarded as myoma, yet the attention will be attracted in many 
cases to the strikingly tense distension of the uterine walls occa- 
sioned by the rapidly-growing neoplasm. This condition recalls 
that of hematometra. 

When a uterus, at first regularly enlarged, develops upon its 
surface one or more knob-like projections and forms adhesions to 
the neighboring organs, the indications are clearly of malignant 
growth. The diagnosis will be made then, however, too late for 
radical operation. 

The whole clinical course of cancer of the uterus should excite 
suspicion. The return of irregular hemorrhages after menstruation 
has ceased, often for years, should arouse the suspicion of cancer if 
there are no polypi in the endometrium or cancer of the cervix to 
account for it. The eventual occurrence of bad-smelling discharges 
and the perceptible increase in the size of the womb will confirm 
the suspicion. On the introduction of the sound the irregularly 
degenerated surface of the growth may be felt, and frequently the 
sound, used without force, will penetrate the masses, and, indeed, 
perforate the womb, as happened once in our hands. These clin- 
ical symptoms are so clearly indicative of cancer that hardly a 
doubt should remain as to the dias-nosis. 

Microscopical examination of excised pieces should always be 
made. The pieces are removed at different positions of the growth 
with a sharp spoon. The operation is attended with neither suffer- 
ing nor harm to the patient, and renders the diagnosis sure before 
the corroborative symptoms of the later stages have developed, 
which place the patient beyond the pale of operative interference. 

Cancer of the womb, from a curative point of view, must be 
regarded in its incipient stage, before it has progressed to fixation. 
In the course of its advance the lymph-glands which lie behind the 
peritoneum of the posterior abdominal wall, and the lymphatics at 
the point of attachment of the ligamentum latum upon the abdom- 
inal parietes, are the first to become affected. The palpation of 
these glands is extremely difficult, if not impossible. So in cancer 
of the uterine body it can never be absolutely determined whether 
the radical operation will be attended with a return of the disease 
or not. It can be decided only that the performance of the opera- 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 385 

tioii is feasible. For this reason the prognosis in cancer of the 
body is perhaps less favorable than in that of the cervix. Yet, 
on the other hand, cancer of the body of the womb is slower in 
attacking peri-uterine structures. 

The sole treatment for cancer of the womb, wherever situated, 
whether in the neck or the body of the womb, before infiltration of 
the adjoining tissues has taken place, consists in the complete 
removal of that organ with its ovaries and tubes, either through the 
vagina or by the abdominal incision. When the womb is not much 
enlarged, vaginal hysterectomy should be our choice on account of 
the greater simplicity of the operation, the shorter time required 
for its performance, the greater comfort of the patients during their 
convalescence, and the avoidance of an unsightly scar and of the 
risk of subsequent ventral hernia, which frequently follows abdom- 
inal section. The womb may become so large, however, that its 
removal by the vagina is an impossibility. We have then, of 
necessity, to remove it from above through the abdominal incision 
or through the sacrum. 

In uterine cancer, if the vagina is not implicated, if the disease 
has not travelled along into the broad ligaments, and if the womb 
has not been fixed by adhesions, the immediate and remote success 
attending the operation of the complete removal is an extremely 
satisfactory one. The averages of immediate and permanent recov- 
ery compete most successfully with those of the excision of the 
breast for cancer. Thus, out of 474 cases operated upon by five 
principal operators in Germany and collected by Winter, 40 died 
from the operation — a mortality of 8.4 per cent. Individual opera- 
tors have done better than this : Kaltenbach having lost 3.3 per 
cent.; Leopold 4 out of 80 vaginal hysterectomies; and Stande 1 
out of 22. On the other hand, of 778 cases of excision of the 
breast collected by Koester, the immediate mortality reached 15.6 
per cent. Experience greatly lessens the rate of mortality in the 
extirpation of the womb. For instance : Pean lost 7 out of his 
first 22 cases, and none out of his next 16 cases. 

As regards permanent success, cancer of the breast is discovered 
earlier, and is therefore operated on earlier, while cancer of the 
womb is rarely discovered until it has so far advanced as to have 
insidiously implicated contiguous and continuous structures. Even 
when it is discovered, being seated in an unseen organ, its dangers 
are not realized and operative interference is liable to be postponed, 

25 



386 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

Hence one would infer a larger measure of permanent success in 
extirpation of a mammary cancer. Yet, from our own personal 
experience, and from a careful statistical inquiry into the experience 
of others, we are thoroughly convinced that the removal of the 
womb per vaginam, for cancer, far surpasses in its remote or perma- 
nent success, not only all other operations for cancer of the womb, 
but also all operations for cancer in other parts of the body. Nor 
need we wonder at this success, because the lip, breast, penis, and 
rectum, which are the favorite sites for cancer, are integral parts 
and parcels of the body, while the womb is to the body only an 
appendage, which is merely suspended by stays and guys, and these 
of a different or mongrel tissue. 

We all know how liable cancer is to return in the breast even 
when discovered early and the whole mammary gland has been 
removed. Cancer of the lip or of the penis behaves no better, 
while cancer of the rectum always returns, no matter how early or 
how thorough has been the extirpation of that gut. On the other 
hand, let us consider the statistics of those gynecologists who have 
removed the womb for cancer. At the end of five years Fritsch 
had 36 per cent, of cures ; Hoffmeier had no return after four years 
in 33 per cent, of his cases ; at the end of two years Schauta of 
Prague found 47.3 per cent, of his patients free from the disease ; 
Olshausen, after the same length of time, reports 19 out of 40 with- 
out a relapse. The careful statistics of the Dresden Klinik exhibit 
the following remarkable results : Of 80 patients examined over two 
years after the operation, 45 were without any recurrence ; of 58 
patients examined after three years, b^.Q per cent, were well ; of 42 
patients after four years, 59.5 per cent, were found free from the 
disease ; of 30 after five years, 60 per cent ; of 9 after six years, 
QQ.Q per cent, had no return ; whilst two women who had survived 
the operation seven years were perfectly well. The best showing, 
however, is by Leopold, who states that out of 76 of his cases 
remaining under observation after recovery, 72 were still well, with- 
out recurrence of the disease, from one to five and a half years after 
the operation. In view of these facts we are warranted — indeed, 
we are compelled by duty — to operate whenever we can do so safely 
in a case of cancer of the womb, and that by the complete extirpa- 
tion of the whole womb. Every other operation aiming at the 
removal of only the diseased portion of the womb is a delusion and 
a snare. 



PLATE XVIII. 
Fig. 1. 




Fig. 2. 



Fig. 1. — Vaginal Hysterectomy with Clamps. Single-clamp operation. 

Fig. 2.— Vaginal Hysterectomy with Clamps. Multiple-clamp operation : first step. 



MALIGNANT DISEASES OF THE FEMALE GENITALIA, 387 

Whilst, undoubtedly, the general consent of gynecologists has 
fixed upon the vagina as the best channel through which the womb 
should be extirpated, whether for cancer or for incurable prolapse, 
yet the same unanimity does not exist with regard to the technique 
of the operation. Some surgeons, at the head of whom stand Pean 
and Richelot, secure the broad ligaments, either in section by 
several catch-forceps or as a whole by a single clamp on either side. 
Many, perhaps the majority of American surgeons, have adopted 
this mode of procedure, and there is hardly one who has not 
invented some form of clamp. This is usually a more rapid mode 
of operating, and the clamps are kept on only from thirty-six to 
forty-eight hours ; but it has its objections. First, the ends of the 
clamps or the beaks of some of the forceps placed higher up must 
protrude into the peritoneal cavity of the pelvis, which therefore 
cannot, as in the operation by ligature, be closed above them so as 
to make the stumps extraperitoneal. Consequently, from the break- 
ing down of the tissues in the bite of these instruments the pelvic 
and intestinal peritoneum is liable to be infected by putrilage. 
Especially will this happen when the bruised stumps, released from 
the weight of the clamp-forceps, spring back into the peritoneal 
cavity. Second, the large open channel between the abdomen and 
the vagina invites contamination of the contents of the former. 
Another objection is the possibility of the clamp catching one of the 
ureters in its bite. This unfortunate accident has repeatedly hap- 
pened, and it is always a fatal one. Again, there is, after the use 
of the clamp, a liability of intestinal adhesion to the margin of the 
wound, causing fatal obstruction. This has happened so frequently 
as to make some operators return to the use of the ligature. Fur- 
ther, the obstruction of the vagina by the presence of such bulky 
instruments makes the removal of the distant tubes and ovaries dif- 
ficult, if not in some cases impossible. Finally, the danger of fatal 
hemorrhage from the slipping off of the forceps is far greater than 
when ligatures are used. It is true that in those cases in which, 
by inflammatory exudation, the broad ligaments have become so 
shortened and so rigid as to make the application of ligatures very 
difiicult, or indeed impossible, clamps and catch-forceps may be 
indispensable. But it is in precisely such cases that the operation 
of extirpation is, in our opinion, of questionable advantage. For 
usually such a condition of the broad ligament is brought about by 
the extension of the malignant disease, and not by a mere infiam- 



388 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

matory exudation of a benign character. Nor, if caused merely by 
inflammation, are the immediate results so good as when the womb 
is freely movable. 

The objections to the progressive silk ligatures are less grave, 
and they are as follows : AVhen applied to the short and dense 
stumps of the broad ligaments they are liable to slip off. Then, 
again, it is true that while by their use most of their knots and the 
included portions of the broad ligaments can be made extraperitoneal 
by closing the roof of the vagina above them, some of the knots of 
the upper ligatures will usually lie in the peritoneal cavity. Con- 
sequently, since one of each of the free extremities of the silk 
ligatures must not be cut off, but be left long in order to facilitate 
their ultimate removal, there will be a liability of capillary drain- 
age along these ligatures from the unclean vagina into the peritoneal 
cavity. This invites blood-poisoning, or, what is not uncommon, 
local abscesses, because the knot, which may hang on for three, four, 
or even six weeks, as we have known it to stay on, becomes con- 
verted into a septic foreign body. 

Now, catgut ligatures are not open to these objections. If 
applied directly from the alcoholic solution in which it is kept, and 
unmoistened by water, catgut swells up immediately, and binds 
more firmly than before the tissues around which it is tied. It is 
therefore less liable than silk to slip off. We have, indeed, never 
known a catgut ligature to slip off, even when applied to the short 
and thick broad ligaments of a fibroid tumor of the womb and to 
its very large blood-vessels, which have to be tied during the ope- 
ration of suprapubic hysterectomy. Then, again, in vaginal hys- 
terectomy the catgut ligature has this very great advantage over the 
silk ligature : that each ligature, high or low, intra- or extra- 
peritoneal, can be cut off close to its knots. Hence those knots left 
in the abdominal cavity are not only absorbable, and therefore less 
likely to become foreign bodies, but by the sewing up of the wound 
in the vaginal roof, also by catgut, they are cut off from the vagina, 
and therefore from vaginal contamination. Lastly, all the ligatures 
will take care of themselves by absorption, and do not need, weeks 
after the operation, repeated vaginal examinations and repeated tugs 
before they can be dislodged. 

The dangers of vaginal hysterectomy, however performed, are 
sepsis, hemorrhage, vesico-vaginal fistula, and injury to the ureters 
by the clamp or by the ligature. Therefore that surgeon who care- 



PLATE XIX. 
Fig. 3. 




Fig. 4. 



Fig. 3.— Vaginal Hysterectomy with Clamps. Multiple-clamp operation : second 
step 

Fig. 4.— Vaginal Hysterectomy with Clamps. Multiple-clamp operation : third 
and final step. 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 389 

fully avoids these dangers will in the long run be the most suc- 
cessful. 

The technique which we now prefer to follow is a blending of 
what seems to us to be the best points in Martin's and Olshausen's 
operation. The cervix is first thoroughly curetted, and afterward 
charred by Paquelin's thermo-cautery. The funnel-shaped excava- 
tion is next stuffed with iodoform gauze, and its lips are sewed 
closely together by a continuous suture. These precautions are taken 
to prevent contamination of the peritoneum from any uterine leak- 
age. The vagina now gets a thorough cleansing with a soft-soap 
solution, and is swabbed out with a 1 : 1000 bichloride-of-mercury 
solution. The woman being placed in the lithotomy position, the 
parts are covered with a sterilized napkin having a slit correspond- 
ing to the vulvar orifice. Not to be short-handed, four assistants 
are needed : one to give the ether, one at each knee, and the fourth 
to be seated by the side of the operator in order to render him close 
and- frequent help. The vagina being expanded by a short duck- 
bill speculum and by two retractors, the cervix is seized by a double 
tenaculum forceps, dragged downward and upward, and Douglas's 
pouch opened. Aided by the forefinger of the left hand introduced 
within the opening, a running suture of catgut unites the peritoneal 
edge of the incision to its vaginal edge ; in other words, the rectal 
edge of the vaginal incision is whipped over. This is a very 
important procedure, both because it prevents the stripping off of 
the peritoneum during the subsequent manipulations, and especially 
because it prevents any hemorrhage, which is very likely to take 
place from this wound several hours after the operation. To pro- 
tect the peritoneal cavity and to keep the intestines from protruding, 
a sponge or a roll of iodoform gauze, to which a strong thread is 
attached, is pushed up through the opening in Douglas's pouch. 
To distinguish this thread from the numerous other ligatures a 
small piece of gauze is tied to its free extremity. The cervix being 
now dragged backward and downward, a transverse incision is made 
across its anterior surface above the os uteri, beginning and ending 
at the first incision, and the bladder is stripped off with the finger, 
with the knife-handle, and with an occasional nick of the scissors 
until the utero-vesical fold of the peritoneum is reached and opened. 
Here also is the vesical edge of the vaginal incision whipped over 
with catgut, so that now the whole vaginal wound is secured against 
hemorrhage. 



390 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



Wh^n the bladder has been stripped up off of the womb, and 
not before, lest the ureters should be included in the ligatures, the 
broad ligaments are tied off in the following manner : 

By means of two aneurism needles, curved to the right and to 
the left, successive portions of the broad ligament on each side are 
tied with gut ligatures and cut off from the womb ; but the free 



Fig. 270. 




Vaginal Hysterectomy : Opening the posterior cul-de-sac, and suturing the peritoneum and the mucous 

membrane together to control bleeding. 

extremities of the ligatures are, for the time being, left uncut. As 
the womb is thus gradually freed, it descends lower and lower, until, 
all its attachments being severed, it js extirpated. Sometimes this 
can be greatly facilitated either by retroverting or by anteverting 
the womb, and by delivering its fundus respectively through the 
posterior or the anterior vaginal incision. This maneuvre is brought 
about by the fingers in the anterior opening pushing the fundus back- 
ward, or vice versa. The fundus is then seized and drawn out by the 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 391 

tenaculum forceps, or it is hooked out by the old-fashioned obstetric 
crotchet. By this forward or this backward displacement, as the 
case may be, the broad ligaments get a half twist upon themselves, 
which not only reduces their width by one-half, thus lessening 
the number of ligatures needed, but which also places their upper 
and more distant portions within easy operative reach. Whenever 
possible, the ovaries and tubes should also be ligated and removed, 
because these organs, being the next ones most liable to be attacked, 
may already contain cancer-germs, and because the woman should 
not be subjected to the annoyance of the now needless function of 
menstruation. 

When the womb has been extirpated the sponge or the gauze 
tampon is removed, the free extremities of all the ligatures on the 
left broad ligament are seized with the left hand, and the stump on 
that side is drawn below the level of the opening in the vaginal 
roof. To keep it in this position it is sewed by one or two cat- 
gut sutures to the corresponding end of the incision. The same 
thing is done to the right stump, and all the ligatures — if of cat- 
gut — are cut off close to their knots. We ought to have said that 
before this is done the ligatures — say those on the tube and ovary 
— lying too high to be made extraperitoneal are first cut off close 
to their knots. A strip of iodoform gauze for drainage purposes is 
now pushed up into the pelvic cavity through a small opening left 
in the vaginal roof, and the vagina is loosely packed with iodoform 
gauze. On the third day the bowels are moved, and after that both 
strips of the iodoform gauze — the drainage strip and the vaginal 
tampon — are removed. No kind of vaginal douche should be used 
for a week, and then only with great gentleness for fear of tearing 
open the newly-united parts. 

There are some excellent surgeons who prefer to close up wholly 
the vaginal wound, and to use no kind of drainage whatever. In 
unquestionably clean operations this plan is, in our opinion, war- 
rantable. But since the vagina is an unclean canal, and the disease 
itself is septic to the last degree, one can never be sure that one's 
operation has been free from infection. Hence in the long run it 
seems to us that drainage would be safer, and we have very gener- 
ally resorted to it. 

When the vulva and vagina are ample and the womb is not much 
enlarged, this operation is usually an easy one. But when opposite 
conditions exist, such as may be found in aged women, and espe- 



392 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

cially in old maids, the operation is a very difficult one. It may 
then demand vulvo-vaginal incisions to increase the working room, 
OT it may have to be completed by a final resort to abdominal 
section. 

For the first twenty-four hours after the operation nothing what- 
ever should be given to the patient excepting sips of hot water or of 
hot weak tea without sugar or milk, and for flatus an occasional tea- 
spoonful of old whiskey ; but even these should be given sparingly. 
After that time tablespoonful doses of milk, of beef- tea, or of bar- 
ley-water may be given every two hours. This diet may then be 
increased after the bowels have been moved. If during the first 
twenty-four hours nourishment seems indispensable, or if, later on, 
more nourishment than that given by the mouth is needed, resort 
should be made to enemata of peptonized milk or of beef- tea with 
whiskey. The convalescence in these cases is usually remarkably 
prompt, so much so as always to surprise one, although now the 
author has had a pretty large experience with them. The absence 
of all constitutional disturbance, the freedom from pain, and the 
ability of the patient to turn from side to side at will are in striking 
contrast to the ordinary features of an abdominal section. 

Sometimes, as has been intimated, on account of the size of the 
diseased womb or of the narrowness of the vagina, or of uterine 
adhesions situated so high that they cannot be reached from below, 
the womb may have to be removed by an abdominal section. This 
operation will be described elsewhere, and its details are therefore 
not given here. Yet it w^ill not be out of place to remark that in 
such cases it is often well to begin the operation per vaginam, and 
to end it by coeliotomy. Of course the most scrupulous antiseptic 
precautions must be taken, because the risk of infecting the peri- 
toneal cavity is now greatly enhanced. Trendelenberg's position is 
the one best suited for this abdominal section, as it permits every 
step of the operation to be readily seen. 

Attempts have been made to remove the uterus through other 
avenues of approach; thus hysterectomy has been performed 
through a transverse incision in the perineum, the recto-vaginal 
septum being divided. Methods have been devised for entering 
the abdomen through incisions to the right or to the left of the 
coccyx, extending from the sacro-coccygeal articulation, curving 
slightly outward to a point two or three centimetres from the four- 
chette. Through either of these incisions the operator reaches the 



PLATE XX. 
Fig. 1. 




Fig. 2. 



Fig. 1.— Vaginal Hysterectomy with the Ligature : first step. 
Fig. 2.— Vaginal Hysterectomy with the Ligature : second step. 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 393 

ischio-rectal fossa. A part of the gluteus maximus is resected, the 
sacro-sciatic ligaments and the levator ani muscles are cut through, 
and the rectum is detached from the vagina. The vaginal cul-de- 
sacs are then opened and the hysterectomy performed. The opera- 
tion by the sacral method, devised by Kraske, is of all these methods 
the best, as it is the easiest of execution and affords the largest open- 
ing for manipulation. The patient is placed in the right lateral 
decubitus, and after preliminary antiseptic preparation of the parts 
and the plugging of the rectum with antise23tic gauze, a curved 
incision is made on the left side of the coccyx, extending from its 
tip to the middle of the sacro- iliac symphysis. The periosteum 
covering the coccyx is stripped off and the coccyx extirpated. The 
lower portion of the sacrum, up to the lower border of the third 
sacral foramen, is removed by cutting forceps. The distended rec- 
tum is easily recognized and displaced laterally. The peritoneum 
in Douglas's pouch is now picked up and incised, and the abdom- 
inal cavity opened for the hysterectomy, which is performed in the 
same manner as in the vaginal operation. The principal accident 
which may occur in the performance of this operation is the wound- 
ing of the rectum or the severing of one of the ureters. Should 
the first occur, it should be immediately closed by a running suture 
with fine catgut. A ureter if severed, provided the ends cannot be 
reunited by sutures, should be turned into the rectum or into a near 
coil of intestine, while the end attached to the bladder should be 
ligated and closed. It would probably be better to remove the cor- 
responding kidney at once, as the subsequent trouble with the 
bowels, induced by the pressure of the urine, would most probably 
necessitate this step at a more or less remote period. On account 
of the extensive separation of the tissues it is well in closing the 
wound to provide for drainage. This method provides for the 
removal of uteri too large to be excised through the vagina. The 
operation through the abdominal incision is, however, in every 
respect preferable. 

Cancer of the Ovary. 

Carcinoma of the ovary is usually secondary to a carcinoma of 
the womb or of some other organ. Primary ovarian cancer may 
occur, however, and appears to have no relation with the age of the 
individual. It has been observed before puberty. Usually both 
ovaries are involved. 



394 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



Primary ovarian carcinoma appears in two forms — as a diffuse 
cancerous infiltration of the ovarian stroma, or as a tumor growing 
from the periphery of the organ. 

In the first form the ovary is usually uniformly converted into a 
cancerous mass, preserving its form, although it may reach an enor- 
mous size. Ovarian cancers of this class have been observed as 
large as a man's head. Rarely, several cancerous masses may form 

Fig. 271. 




Section of an Ovary, showing its surface covered with papillomata. 

in the ovarian tissue, which, growing rapidly, give rise to an irreg- 
ularly shaped tumor. 

In the second form of ovarian carcinoma the growth forms a 
cauliflower-shaped mass which projects from the surface of the 

Fig. 272. • 




Papillomatous Cystic Tumor of the Ovary. 



ovary. It consists of a papillary proliferation rich in blood-vessels 
and covered with cylinder epithelium. This form of carcinoma of 
the ovary leads early to ascites and to the infection of the perito- 



PLATE XXI. 
Fig. 3. 




Vaginal Plysterectomy with the Ligature : third step. Fundus dragged into vagina 
prior to placing iinal ligature. 



Fig. 4. 




Vaginal Hysterectomy with the Ligature : stumps drawn into the vagina, with 
sutures in place ready to close the opening in the vaginal vault. 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 395 

neum. Small papillary growths form on the peritoneal surface, 
soon becoming carcinomatous. 

Of much more frequent occurrence is the cancerous degeneration 
of cystomata of the ovary. These appear either as the epithelio- 
matous form, having its origin in the papillary proliferation of a 
cystoma, rapidly leading to infection of the peritoneum and to 
ascites, or as a pure glandular type of carcinoma forming in the 
tissue of the ovarian cystoma. 

The ovarian carcinoma soon excites profuse ascites and chronic 
peritonitis from its irritation of the peritoneum. It spreads rapidly 
by circumscribed nodular formation to the neighboring organs, and 
through the broad ligament to the pelvic connective tissue. It may 

Fig. 273. 




Papillomatous Disease of the Broad Ligaments, completely hiding the appendages. 



perforate the covering tissues of the ovary, and proliferate, fungus- 
like, in the cavity of the pelvis. The epitheliomata infect the peri- 
toneum much earlier. 

The primary symptoms do not differ from those of benign 
enlargements of the ovary. The tumor grows, however, more 
rapidly. Symptoms of chronic peritonitis exist. A symptom of 
much diagnostic importance is the early oedema of the feet and 
ankles from pressure upon the great vessels of the pelvis. The 
condition of the patient continues to grow worse until death occurs 
from peritonitis, marasmus, stricture of the bowel, or from uremia. 

The marked distension of the abdomen from ascitic fluid usually 



396 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



first causes the patient to seek advice. Soft, compressible masses in 
Douglas's pouch may then be felt. It is usually necessary to draw 
off the ascitic fluid by a small median incision or by tapping in 
order to make an absolutely certain diagnosis. The relaxed abdom- 
inal walls then permit an easy examination of the pelvic organs, 
and the irregularly -enlarged ovary or cauliflower-growth may be 
clearly detected if the process has not progressed so far as to involve 
the entire pelvis and render the ovary a highly probable point of 
origin. 

The TREATMENT instituted depends upon whether secondary 
involvement of the peritoneum has taken place. If this has not 
occurred, ovariotomy should be performed at once. Frequently, 
after opening the abdomen, the operator will .find, to his disappoint- 
ment, the impossibility of complete removal. If the infiltrated 
base of the growth is to be felt extending into the pelvic cellular 
tissue, or nodules are found in Douglas's cul-de-sac, the operation 
should be abandoned, as attempts at removal of the growth would 
only hasten the end. 

Saecoma of the Ovary. 

Sarcoma of the ovary is of rare occurrence. It is usually of the 
spindle-cell variety and aflPects both ovaries. It has been observed 



Fig. 274. 




Sarcoma of both Ovaries. 



MALIGNANT DISEASES OF THE FEMALE GENITALIA. 397 

in girls eight years of age. The growth develops from connective 
tissue of the ovarian stroma, which normally contains short spindle- 
shaped cells. Sarcomatous tissue is frequently found in dermoid 
cysts, and growths resembling sarcoma microscopically often follow 
their removal. The spindle-cell ovarian sarcoma is attended with 
considerable vascular development, which gives the growth a cavern- 
ous appearance. The Graafian follicles may become dropsical, and, 
increasing rapidly in size, produce a cystic complication of the 
sarcoma. 

The sarcomatous tumor preserves the shape of the ovary, and 
mav reach a considerable size. Tumors of this kind have been 
reported weighing eighty pounds. 

The DIAGNOSIS is difficult. A large solid ovarian tumor is easily 
recognized. Such a growth is probably sarcomatous if of rapid 
growth, possessing a smooth surface, and attended with ascites, 
especially if the patient be young and both ovaries be tumefied. 

The TREATMENT is whoUy surgical. Sarcomata of the ovary do 
not rapidly involve the neighboring tissues, nor do they give rise 
to early metastasis. After removal they are not so prone to return 
as the carcinomata. Still, one is not sure of complete cure by extir- 
pation even in the most favorably appearing cases. The author has 
had perfect cures from the removal of the cyst ; then, again, he has 
seen the disease return very soon ; but in one case it did not return 
for five years, during which time the woman enjoyed good health. 



UTERINE NEOPLASMS. 

Fibroid Polypi. 

Cervical. — These are always more or less pedunculated, generally 
with slender stems. True fibroid polypi arising from the cervix 
are not common. More generally is it the case that cervical polypi 
are of glandular origin. 

As in the illustration, the gross appearances of the growths 
where they contain much fibrous tissue, strongly resemble malig- 

FiG. 275. 




Small Muriform Polyp of the Cervix (papillary fibroma with glandular hypertrophy). 

nant disease, and the diagnosis may rest entirely on the microscopic 
appearances. 

Cervical polypi, being exposed to the vaginal filth, usually pro- 
duce a nasty, purulent discharge, profuse and ill-smelling. There 
is always more or less general glandular endocervicitis with them, 
the cervix being as a rule widely gaping and eroded. They do 
not reach a large size. If the pedicle be long and the mass hang 
entirely outside the cervix, strangulation may ocdur in the growth 
and a spontaneous cure ensue. 

Uterine. — These are merely transitional between the mucous 
polypi already described and submucous fibroids. They are de- 



398 



UTEBINE NEOPLASMS, 399 

scribed by many authors as the result of the uterine contractions 
forcing the submucous fibroids into a pedunculated form — an 
attempt at spontaneous cure. The uterus being in a condition 

Fig. 276. 




Intra-uterine Fibroid Polyp. 

of chronic metritis is always more or less enlarged, and its cavity 
is distended. Purulent endometritis is a common accompaniment, 
and general glandular hypertrophy is usually present. 

Some of these polypi have short stems, but their pedicles may 
be so long as to cause the bulb of the polypus to hang from 
the vulva. Unlike the glandular variety, fibroid polypi are usually 
single. 

Symptoms. — These are very similar to those occasioned by small, 
submucous fibroids. There are pronounced uterine cramps, puru- 
lent discharge, increased menstruation, hemorrhage, backache, and 
a sense of weight in the pelvis, as common symptoms. The dis- 
charge is profuse generally, and the bleeding is marked. There 
may be a continuous oozing all the time, or the bleeding may occur 
as hemorrhages, very profuse and alarming. Fibroid polypi are not 
easily mistaken for other growths when once seen and felt. 

Treatment. — Fibroid polypi are not amenable to medical treat- 
ment. Pedunculated fibroid polypi from the cervix may readily be 
removed by torsion. Should the base be firm or broad, it may be 
severed with the scalpel and a few sutures taken to correct the 
hemorrhage and approximate the cut surfaces. 

Small polypi from the body of the uterus may also be removed 
by torsion, but it is better to combine with this curettage and gauze 
packing if the general endometrium be, as it usually is, much hyper- 
trophied. 

Large polypi are occasionally quite formidable affairs. In case 
the finger cannot be introduced into the vagina at all, owing to the 



400 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



size of the growth, it is proper to cut away enough tumor to enable 
the passage of the finger and stout forceps. The pedicle is sought 
for and secured by forceps, when the growth is to be cut away. The 
pedicle may be twisted or sutured. As these growths are unclean, 
irrigation and gauze dressings are indicated. It must not be for- 
gotten that in old women malignant disease is apt to supervene 
upon any long-standing inflammatory condition of the inside of the 
uterus. Therefore it is always well to submit the curettings and 
the polypus to the microscopist for examination. 

Uterine Fibroids. 

Pathology. — Uterine fibroids are composed of an increased 
growth in the fibrous and muscular structures of the organ ; they 

Fig. 277. 




Uterine Fibro-myoma, microscopic view. 



are generally, then, fibro-myomata. They are non-malignant 
tumors, but not infrequently is malignant disease associated with 
existing fibroid. They may occur just beneath the uterine mucous 
membrane, or deeper in its walls, or immediately under the peri- 
toneum. They are then known as submucous, interstitial, or 
subserous. They are prone to occur in nests or groups, and the 
several varieties are very often associated ; precise classification in 
such a case is not possible. In gross appearances these tumors 
are of a. deep red color or pale. They are firm, and under the knife 
cut like gristle when the fibrous tissue predominates, but are less 
firm when the muscular fibres are in excess. Upon section the 
striations of bundles of fibre may be seen, and nests of fibrous 
tissue bulge from the cut surfaces as nodules. Their walls may 



UTERINE NEOPLASMS. 



401 



contain cysts filled with clear, bloody, or purulent fluid. They are 
prone to undergo various degenerative processes — cystic, myxo- 



FiG. 278. 




Submucous Uterine Fibroma. 



matous, fatty, and even calcareous degeneration. There are two 
forms of cystic degeneration — one due to myxomatous changes ; 



Fig. 279. 




Submucous Fibroid Tumor of the Uterus : the uterus is laid open, showing the fibroid cut in two ; 

also cavity of the uterus. 

the other, more common, due to lymphangiectasis — distension of 
the intermuscular lymph-spaces. 

26 



402 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



Fibroid and fibro-cystic tumors occur of any size, from that of 
a pea to the largest, weighing one hundred and ninety-five pounds, 



Fig. 280. 




Large Fibrous Interstitial Tumor of the Uterus. 



removed by Severanu. They arise from any part of the body of the 
uterus, and less frequently also from below the os internum. Large 




A, Subperitoneal Pediculated Fibroid ; B, left kidney ; C, Wolffian cyst ; D, interstitial fibroid contained 
in the right cornu of the uterus ; E, insertion of the peduncle of the large tumor on a level with the 
left cornu ; F, left ovary and round ligament ; G, right ovary and round ligament ; H, cervix. 



subserous tumors are covered with enormous veins, and all fibroids 
are generously supplied with blood. According to size and locality, 



VTERINE NEOPLASMS. 
Fig. 282. 



403 




Interstitial Fibroid. 



they may form attachments to almost any of the abdominal organs. 
Pedunculated fibroids from torsion of the pedicle may slough. 
In addition to the above degenerative changes, fibroids may 



Fig. 283. 




Calcareous Degeneration of Fibroma, showing the calcareous nodules. 



404 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



become infected and undergo inflammation, with the production 
of pus, or even become gangrenous. Finally, the mucosa of the 
fibroid uterus may become epitheliomatous, or the connective tissue 
may be infiltrated with sarcomatous elements ; and it is not uncom- 
mon to find cancer of the cervix coexisting with fibroid of the body. 
The cell-proliferation arises from the adventitia of the arteries, and 
the tendency to it is probably congenital. 

Wyder has shown that there is nearly always an endometritis 
of a glandular, hypertrophic character, associated with fibroid. 

Fig. 284. 




Pediculated Fibroid with Abdominal Evolution : MS, fibroid lobe ; MC, fibro-cystic lobe. 



The Fallopian tubes are the seat of interstitial change also, and 
may contain bloody or purulent fluid, and the ovaries are usually 
enlarged, with thickened capsules. 

Various interstitial changes are produced in the important vis- 
cera, chiefly by obstruction to the vascular circulation, as fatty 
liver and nephritis. Large tumors are also associated with con- 
servative hypertrophy of the left heart. There are two forms of 
heart degeneration, which are quite common in advanced cases, and 



UTERINE NEOPLASMS. 



405 



known as brown and fatty degeneration. Fibroids occur before 
middle life as a rule, and have even been noticed before puberty. 

More or less peritonitis is to be found in connection with the 
large tumors, binding them to the viscera. The omentum espe- 
cially is prone to become attached to them, thus lending to the 
growths a new and increased blood-supply. Large blister-like 
accumulations of serum often occur just under the peritoneum 



Fig. 285. 




Enlarged Blood-vessels on the Surface of a Multinodular Subserous Fibroid Tumor of Uterus. 

adjacent to the sides of the large tumors, and more or less ascites 
accompanies them. 

Symptoms. — Some fibroids, even of considerable size, give rise 
to no symptoms at all for some time, the patient merely noticing in- 
crease in her girth. Symptoms are due to the situation rather than 
to the size of the tumor. Subserous tumors give rise to pressure- 
symptoms chiefly, while hemorrhage is the most marked symptom 
of the submucous and interstitial varieties. But one subject may 
present all the various forms. 

Pain, — This is very marked where the tumor causes a general 
distension of the uterine walls. Like all uterine pains, it is pro- 
ductive of hysterical symptoms. There are other pains, paroxysmal 
and from contraction of the uterine muscle, due to the irritating 
presence of the tumor. Local pain is less commonly attendant 



4Q6 AN AMEBICAN TEXT-BOOK OF GYNECOLOGY. 

upon the subserous variety. The greater the tension in the uterine 
walls, the more severe is the pain. Thus it frequently happens that 
there is less pain where the growth has become large and thus 
escaped from the control of the uterine muscle. 

Tumors of size growing from any part of the uterus cause pain 
from pressure on the nerves and adjacent organs. These pains 
radiate down the thighs and through the bladder and bowels from 
obstructed function in those viscera. Pressure-pains are most 
marked with tumors which are yet in the true pelvis. When the 
uterus and neoplasm have risen above the brim of the pelvis, they 
have a greater range of mobility. Menstruation and other bleed- 
ings increase the pains markedly in some cases. 

Hemorrhage, — The menstruation first begins to be increased in 
amount. After a while the flow is extended in time for a few days, 
and an observing patient will appreciate that she is using more nap- 
kins at each successive period. Soon intermenstrual bleedings occur, 
and at such irregular intervals that the patient will lose all record 
of menstruation. She will be free from hemorrhage for weeks, and 
then have a bleeding which will bring her to death's door. This 
hemorrhage is produced from the hypertrophied endometrium, which 
often is in a condition of general polypoid degeneration, but there 
may be profuse bleeding with a membrane which is atrophic. 
Vessels which in the normal endometrium are mere capillaries be- 
come here thin-walled arterioles. These bleedings are often the first 
symptoms of mural and submucous fibroids, even of those of small 
size. Subserous growths may attain considerable size before giving 
rise to marked bleeding. The occurrence of the menopause has a 
favorable efiect upon these growths, but it often never occurs, and 
is always postponed by the tumor. Again, most tumors begin to 
produce marked symptoms at a time when the menopause should 
naturally occur. Moreover, the menopause may merely check the 
bleeding for a time, it recurring after a few years. 

Alternating with the hemorrhages is a leucorrhea. This may be 
a simple whitish discharge, or sanious or purulent according to the 
changes in the endometrium. It is frequently chylous, profuse, and 
particularly exhausting to the patient. 

Pressure-symptoms. — Tumors lying in the true pelvis obstruct 
the rectum, thereby producing retention of feces even for many 
days at a time, and inducing a form of systemic poisoning by the 
re-absorption of excreta — " retention toxicosis." Also, as a result 



UTERINE NEOPLASMS. 407 

of this pressure, hemorrhoids are of common occurrence. The 
action of the bladder is interfered with by pressure on the urethra, 
producing thereby painful and difficult urination, with, ultimately, 
cystitis from retention. 

The presence of large fibroids so obstructs the return flow of 
blood from the legs that there is necessarily a compensating enlarge^ 
ment of the veins of the abdomen. The ureters may be so obstructed 
as to produce hydronephrosis, and ultimately interstitial change in 
these glands, with albuminuria. Dropsy of the legs may occur from 
pressure alone, independently of kidney change. 

General Symptoms. — As a result of the repeated hemorrhages 
these patients are exsanguinated to a considerable degree. In some 
the bleedings are sudden and fierce. These sufler from attacks of 
syncope. In others there is a continuous dribble, with occasional 
floodings, and they present the worst appearance of all, inasmuch 
as there is no interval during which recuperation may occur. 
Many of them are in very good flesh, some even fat. But those 
who have large tumors are emaciated from locking up of the emunc- 
tories and loss of appetite. 

In large tumors producing pressure on the intestines there are 
the symptoms of anorexia, costiveness, foul breath, headache, and 
sometimes vomiting. Even in cases where there is no suppuration 
in the tumor, there may be rise in temperature ; but, as a rule, 
febrile manifestations are indicative of degenerative changes, with 
production of septic material either in tumor or viscera. 

Death from fibroid occurs either from asthenia, due to the con- 
tinuous loss of blood and pressure, or some complication, and even 
from sudden profuse hemorrhage. 

DiAGNOSis.^A. Submucous Fibro-myoma. — The hemorrhages 
are especially severe, and first attract the patient's attention. Irreg- 
ular uterine colic is also frequent. If the tumor is large enough to 
fill the pelvis, all the symptoms due to pressure are present. 

Examination is most satisfactory. The uterine canal is increased 
in depth. Rectal and abdominal palpation show the organ to be 
enlarged in all its diameters, and reveal its shape. Intra-uterine pal- 
pation is perfectly safe, and may be performed by one of two methods. 
That of Vulliet, by packing the- uterine cavity each day with suc- 
cessively increasing pledgets of iodoform gauze, is efficacious, free 
from danger, but painful and slow. Failing to dilate the cervix 
sufficiently for intra-uterine examination by Vulliet's method, 



408 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



incision of the cervix and forcible dilatation are to be employed. 
Dilatation being of sufficient extent, the finger of one hand is intro- 
duced into the uterus, while the other supports the fundus above. 
The submucous fibroid will be found to have made for itself a 
depression on that wall opposite its origin, and the tumor will be 
felt as a smooth, rounded body. The examination finished, the 
uterus is irrigated and a light drain of gauze introduced. If it has 

Fig. 286. 




CEdematous Submucous Fibroid : a, portion of the vagina; h, cavity of the uterus; c, tumor lodged in the 
cavity ot the uterus, covered by mucous membrane (d); e, tumor rising above the surface of the 

been determined to remove the tumor by enucleation at a subse- 
quent day, or if there be too free hemorrhage, the uterus should be 
tightly packed with iodoform gauze. In this way the cervix will 
be kept open for future treatment. These submucous myomata are 
sessile, and never pedunculated. 

B. Interstitial Fibro-myoma. — Frequently a small tumor is 
accompanied by a general fibroid enlargement of the uterus, giving 
rise to the most severe symptoms, and yet the nodule projects into 
neither uterine nor pelvic cavity. The diagnosis here is difficult, 



UTERINE NEOPLASMS. 409 

and with the enlarged uterus the symptoms point equally to car- 
cinoma ; therefore a curettage for diagnostic purposes is proper, as 
it enables the microscope to differentiate absolutely between the 
hypertrophic endometritis of myoma and the cell-proliferation of 
cancer. The shades of difference between aggravated hypertrophic 
endometritis, with enlargement of the muscularis as a sequence, and 
general hypertrophy of the muscular walls, with a small interstitial 
myoma and thickened bleeding endometrium as sequences, are very 
slight. The chief point in distinction is the exact amount of uterine 
enlargement. Examination under narcosis, aided by the micro- 
scopical investigation of pieces removed by the curette, should 
determine the question. At least it will enable us to eliminate 
cancerous and tubal disease. 

Where the interstitial fibroids are large, increased depth of the 
uterine cavity, general enlargement of the uterus, and more or less 
irregularity in its contour, either exterior or on the mucous coat, 
will suffice to make the diagnosis plain. These tumors when large 
produce hemorrhage, expulsion pains, and hysterical manifestations, 
in addition to pressure-symptoms. 

C. Subserous Fibro-myoma. — These tumors are usually multi- 
nodular, and present a great diversity in arrangement. They may 
be sessile or pedunculated. The sessile tumors must be considered 
according to whether they extend between the layers of a broad 
ligament, into the bladder or into the pelvic cavity. 

The diagnosis of sessile subserous fibroids projecting free into 
the peritoneal cavity is easy, the nodule being readily felt upon 
bimanual examination and rectal touch. At the same time, other 
conditions are easily excluded. 

If the sessile fibroid grows from the anterior surface of the ute- 
rus and displaces the bladder, the uterus is usually retroflexed. 
The finger in the rectum may be made to feel the division between 
the uterus and fibroid, or the hand above the pubes may. But not 
always is this sulcus present, and the entire history and surround- 
ings must be critically considered in order that an accurate diagnosis 
may be made. 

Intra-ligamentous fibroids are exceedingly puzzling. They simu- 
late ovarian cysts, broad ligament disease, extra-uterine pregnancy, 
and tubal cysts. Those which project into the broad ligament from 
the side are not especially difficult of diagnosis. They are more 
firm than other tumors in this locality, and the depression above and 



410 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

below between tumor and uterus may be felt. There is not the ten- 
derness which accompanies tubal disease, and there is more mobility. 
Ovarian tumor, for many reasons, may be excluded. Extra-uterine 
pregnancy which has lasted a few months, especially if preceded by 
menorrhagia, is not easily differentiated from fibroid, for it has the 
same tense walls of fibroid. Although there is severe pain, yet 
it is not as lancinating as that of extra-uterine gestation, and is not 
followed by collapse, as is the latter. The pains of fibroid come on 
gradually, whereas the extra-uterine pregnancy first attracts atten- 
tion by the sudden onset of the stabbing pain from the first attempt 
at tubal abortion. There is great difficulty in making the diagnosis 
sometimes, so similar are the histories of the two conditions. All 
fluid accumulations fluctuate, and are thus excluded. 

When the sessile intra-ligamentous tumor grows dowm against the 
floor of the pelvis, it exercises violent and painful pressure upon 
the structures passing under it. The uterus is lifted up and 
immovable. The tumor is not only sessile, but also attached to 
the pelvic floor. Here rectal touch is especially valuable. The cer- 
vix is often so drawn upon for tissue as to be a mere ending to the 
vagina and cul-de-sac. So firmly attached to the pelvis are these 
growths that they seem to spring from the pelvic fascia. Enchon- 
dromata and fibromata of the pelvic floor have none of the general 
symptoms which intra-ligamentous tumors produce, and may thus 
be rejected. 

Dermoid cysts under examination may suggest fibroid, but the 
subjective symptoms of the two conditions will sufiice to differentiate. 

Pedunculated subserous tumors float free in the abdomen with 
long pedicles, or are joined to the uterus by a shorter and more 
firm bond. 

(Edematous tumors simulate ovarian cysts, but the fluctuating 
portions of the fibroid are limited, and there are parts of the tumor 
which demonstrate its character. The diagnosis is often utterly 
impossible. Unless the pedicle be very long and slender, the cer- 
vix grasped with the volsella and drawn down communicates at 
once its motion to the tumor ; with dermoids and other hard cvsts 
it does not. The area of displacement of fibroid is below the pelvic 
brim, that of floating kidney above. Splenic tumors arise from the 
splenic area and may be traced to their origin. Cancerous and 
tubercular omental disease displaces the stomach downward, and 



UTERINE NEOPLASMS. 411 

there is no area of resonance save at the hypogastrium. The 
growth is more rapid than in fibroids, and hemorrhage is wanting. 

Many large fibroid and fibro-cystic tumors never give rise to 
hemorrhages, and the first and sole symptom may be the presence 
of the tumor. This is especially true of the fibro-cystic tumors, 
they causing, compared with the true fibro-myoma, but little bleed- 
ing. They have taken some time to grow, and coils of intestine 
are commonly in front of them, giving a tympanitic percussion-note. 
Almost invariably the cavity of the uterus is increased in depth, 
and rectal touch at least will demonstrate the attachment of the 
tumor to the uterus. 

Treatment. — Sometimes tumors are accidentally discovered, 
produce no symptoms, and never give rise to conditions requiring 
treatment. They remain innocent during all the woman's life. 

The treatment may be divided into non-operative and opera- 
tive. In the former class we shall mention but two methods of 
treating these growths — by the use of ergot and by electricity. 

Ergot Treatment. — The ergot is used both hypodermically and by 
the mouth, and is employed in every form of the tumor — in sub- 
serous fibroid for the purpose of causing shrinking, and in inter- 
stitial and submucous growths not only to cause diminution in 
size, but also, possibly, to cause expulsion of the growth per vias 
naturales. 

Squibbs's aqueous extract (ergotin), dissolved 1 part to 10 of 
water, and 1 grain of salicylic acid added to each half-ounce of 
solution, the whole sterilized, may be employed with a hypodermic 
syringe kept for that purpose. The syringe also should be care- 
fully sterilized before each application. 

Beginning with 1 grain a day, the dosage may be gradually 
increased, the uterine pain governing largely the amount used. The 
same preparation may be used in pill form associated with nux 
vomica or strychnia. Where the tumor is submucous and inter- 
stitial large doses of ergot produce sudden and severe uterine colic ; 
not so much impression is made, however, upon pedunculated 
fibroids. The depressing action of ergot upon the heart should 
not be forgotten, and for that reason it is wise to use strychnia at 
the same time. It is better to use a moderate dose continuously 
with weekly increases than to give enormous doses and intermit. 
Thus, if a patient receives internally 3 grains of ergotin a day and 



412 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

1 grain hypodermically one day in the week, she should take 
enough to cause marked effect upon the uterine muscle. 

There can be no question as to the effect of the drug. The most 
careful observers are unanimous in testifying that it not only relieves 
symptoms, but in all cases reduces the tumor, and a number of cases 
are reported of the voiding of tumors under its use. There is but 
little dano^er in its use, and we have been able to find onlv two 
cases which died while undergoing this treatment. Hydrastis cana- 
densis is also highly spoken of as a substitute for ergot, in doses of 
20 minims of the fluid extract, three times a day. 

Ergot has no effect upon the fluid contents of fibro-cysts. 

Electricity. — The electrical treatment of fibroids is so technical, 
and requires such an assortment of instruments and batteries, that 
information on the manner of using it will be left to special works 
on the subject. Different authors give different instructions as to 
the strength of the current : they range from 15 milliamperes to 
250, or even more. The pain produced by the strong currents is 
excessive. As to the results of the procedure, the latest figures are 
given by Vineberg, gathered from the works of Keith, Engelmann, 
Gautier, and others who are particularly skilled in the method. 
There were 372 cases : 9 cured, 5 died. This is 2.4 + per cent, 
cured and 1.3 + per cent, died — too high a ratio of mortality and 
too low a ratio of cures. The percentage of cures about represents 
the possible percentage of errors in diagnosis. There is another 
certain percentage not mentioned here, but which is, under careful 
investigation, growing. We refer to malignant disease associated 
with fibro-myoma. Electricity is admittedly not applicable to any 
form of cystic fibroma. 

Altogether, the method must be considered purely experimental. 
The above results are certainly not flattering. Surely better results 
have been obtained from the use of ergot, and infinitely better from 
the removal of the uterine appendages, with about the same rate of 
mortality. In all cases where the physician feels he would not care 
to attack these growths radically, in view of the poor results at the 
hands of those who are masters of the method, we would certainly 
recommend the use of ergot or hydrastis to the exclusion of elec- 
tricity, supplemented also by curettage in cases with severe hemor- 
rhage, the results on both the tumor and general economy being 
excellent. 

The treatment of fibroids by galvano-puncture is no longer 



UTERINE NEOPLASMS, 



413 



practised to any extent, and is to be condemned in an uncompromis- 
ing manner. 

Surgical Treatment. — Vaginal Enucleation. — This operation is 
applicable to tumors which may pass the pelvic outlet or those not 
larger than the fetal head. The method is limited to growths which 
are strictly submucous or covered by only a small quantity of mus- 
cular tissue. The cervix is to be dilated by daily packing with 
gauze, and at the time of operation its calibre may be still more 
increased by incisions and forcible dilatation. The operation is 
preferably done in the dorsal position. The patient should be pre- 
pared as for a hysterectomy. If there be not room enough, the 
uterine artery may easily be ligated (see Vaginal Hysterectomy), and 
the cervix split to the vaginal junction. The tumor being located, its 
capsule is seized with a bullet forceps and split with a scalpel from 
above downward. A blunt-pointed curved scissors is then used 
to loosen the capsule from the circumference of the tumor. The 
excess of capsule is then cut off with scissors. The tumor is now 



Fig. 287. 




Removal of Fibroma by Morcellation. 



seized with the forceps, and attempts made to dig it out of its bed 
with the blunt scissors, the point being turned toward the tumor. 



414 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



In this way, alternately snipping connecting fibres and using either 
the closed scissors or an enucleator, but all the time applying firm 
traction on the tumor, it may be loosened from its bed, with the ex- 
ception of a few fibres. It is then seized with a pair of strong forceps 
or hysterectomy volsella and twisted off. If the mass will not pass 
the cervix, it may be split. All loose shreds of tissue and capsule 











Fig. 


288. 












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3 




1^1 


St*.l 


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_ 


SSS^^i 


r 


^y^ 


^ 


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k 




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W --^H 


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* 





Subperitoneal Nodular Fibroid Tumor of the Uterus. 



should be cut away, the finger introduced to see how much damage 
has been done, and the uterus washed out and packed with iodoform 
gauze. The hemorrhage is best controlled by the packing. The 
great danger from this operation has heretofore been sepsis, a thing 
we can now avoid. Even perforation of the uterus is not espe- 



UTERINE NEOPLASMS. 



415 



eially dangerous. Many tumors now removed by hysterectomy are 
amenable to this procedure. The after-treatment consists of the 
administration, hypodermically, of ergotin, frequent irrigation, and 
gauze packing invariably instead of drainage tubing. Most tumors 
formerly subjected to this operation are now preferably extirpated 
from above. 

Applicable to tumors of the submucous and interstitial variety. 



Fig. 289. 




Method of Removal of a Subserous Uterine Fibroid, stitches in place ready for tying. 

morcellation will never occupy a place in surgery. It essentially 
involves incomplete perineal removal of the growths by forceps, 
scissors, and knife, after severe preliminary incisions in cervix 
and uterus. 

Small interstitial fibroids may be removed by total vaginal hys- 
terectomy, the operation being similar to that for cancer. The 
operation is indicated when the mass is very small, gives great pain, 
produces profuse bleeding, or is septic. Coeliotomy is, however, 
preferable. 



416 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



Myomectomy, — It will occasionally happen that the fibroid is 
attached to the uterus by a pedicle so small as to warrant removal 
of the tumor from above with the saving of the uterus. The pedicle 
is subjected to a V-shaped incision and the tumor removed. Sutures 
of heavy silkworm-gut or silk are then used to accurately unite the 
sides of the pedicle. If there is complete control of the bleeding 
without the appearance of strangulation by the sutures, the uterus 
is returned and the abdomen closed. Large pedunculated fibroids 
with stout pedicles must be treated differently. An elastic ligature 
or ecraseur is thrown around the pedicle a little distance from the 
uterus, and the tumor cut away. The pedicle is then brought up 
into the wound, transfixed with stout pedicle needles, and the wound 
accurately closed around the stump, thus treating the stump extra- 
peritoneally. (See Hysterectomy.) 

A. Martin has connected his name with the operation of enucle- 
ation of interstitial fibroids by the abdomen. He removes the 
tumor in a bloodless way by using a temporary elastic ligature, and 



Fig. 290. 





A, Enucleation of an Interstitial Myoma ; B, Disposition of Sutures after Enucleation. 



depends upon his sutures to permanently control bleeding. He 
reports 16 cases — the uterine cavity opened in 10, and 5 deaths. 
It does not appear that anything is gained by this operation, and 
the mortality is high. 

Supravaginal Hysterectomy. — Extra-peritoneal Method. — This 



PLATE XXII. 



Fig. 1. 



Fk;. 2. 










Fig. 3. 



Fig. 4. 



EXTRA-PERITONEAL TREATMENT OF THE STUMP AFTER SUPRA-VAGINAL HYSTERECTOMY. 

Fig. 1.— Transfixion pins and serre-noeud in place prior to remoA'al of tumor. 
Fig. 2. -Abdominal peritoneum stitched to peritoneum of stump below Avire. 
Fig. 3.— Peritoneum closed ; abdominal stitches in place. 
Fig. 4.— Abdominal wound closed ; stump in process of closure. 



UTERINE NEOPLASMS. 



417 



necessitates the treatment of the stump extra-peritoneally. The 
abdomen is opened and the uterus and tumor are turned out through 
the incision. If necessary to accomplish this, the broad ligaments 
are ligated between two ligatures and a rubber ligature drawn taut, 
or an ecraseur is applied around the neck of the uterus. In fastening 
the rubber ligature one knot is tied, and a stout silk (braided) thread 
is thrown over it ; then the second knot in the rubber ligature is 
tied, and the silk thread tied over this second knot. The same may 
be accomplished by grasping the knot in the bite of a pair of 
hemostatic forceps. Thus slipping is prevented. If the ecraseur 

Fig. 291. 




Knot of Rubber Ligature secured from Slipping by Application of Silk Ligature. 

is used, it is carefully tightened. The peritoneum two or three 
inches above the constricting wire is incised completely around the 
tumor, the broad ligaments being by this means allowed to retract. 

Fig. 292. 




Serre-noeiid for Hysterectomy. 



The tumor is then drawn further up out of the incision, thus form- 
ing a smaller and better pedicle. Transfixion pins are made to per- 
forate the pedicle immediately above the wire, and the tumor is cut 
away about an inch above the pins. The stump is held high in the 



27 



418 ^iV^ AMERICAN TEXT-BOOK OF GYNECOLOGY, 

lower angle of the wound, and inspection made of the constricting 
wire to see that it does not include the bladder or ureters in its 
grasp. If in proper position, it may be allowed to remain perma- 
nently, but if not satisfactory, it is loosened and applied at a higher 
level ; the transfixion pins are shifted to a higher point at the same 
time. Should the stump be too large, it must be reduced to a size 
not greater than an inch or two in diameter by cutting the muscular 
and fibrous portions away piecemeal, the wire being carefully tight- 
ened during the procedure. The peritoneum is then closed by 
stitching it to the serous surface of the pedicle below the wire, by 
means of a single silk or catgut suture. The peritoneum of the 
pedicle is closed by drawing it up over the stump by meai^s of a con- 
tinuous whipped silk suture. Throughout the whole procedure the 
ecraseur is continually tightened by turning the screw. Unless this 
precaution be observed the tissue of the stump shrinks under the 
pressure of the wire, and bleeding would soon occur. If the rubber 
ligature be used, this precaution need not be observed. The abdom- 
inal walls are closed in the usual way by interrupted silkworm-gut 
sutures, passing through all the tissues but the serosa. After the 
stump and surroundings have been thoroughly dried an iodoform 
gauze dressing is applied. Pads of gauze are slipped between the 
transfixion pins and the skin, and are also packed carefully about 
and over the stump, iodoform having been freely dusted over and 
rubbed into the stump. The whole is covered with a thick gauze 
pad and held in place by a three- tailed abdominal binder. 

This operation can be performed very rapidly, and is applicable 
to all tumors with the exception of those which burrow between 
the broad ligament folds, and septic tumors, where the sepsis involves 
the neck or pedicle. The pedicle dries up and gradually melts off 
into the dressings or comes away as a solid mummified mass. The 
first dressing is made on the eighth day, when the stitches are 
removed, the ecraseur having been kept tight by turning the key 
several times daily. The stump is ready to come off in from two 
to three weeks. If it does not come away itself in that time, it is 
best to remove the wire and pins and cut it away. 

The stump sinks deeply into the pelvis, leaving a tube of granu- 
lating tissue, which is packed with gauze and which gradually closes. 
The question of drainage must be settled by the necessities of each 
individual case. As a rule, it is unnecessary. 

There is, of course, a break in the parietes at the position of the 



PLATE XXIII. 
Fig. 1. 




Fig. 2. 



Fig. 1.— Supra-vaginal Amputation of the Uterus: first step. Position of second ligature shown. 
Fig. 2.— Supra-vaginal Amputation of the Uterus : cervix amputated by wedge-shaped incision. 



UTERINE NEOPLASMS. 



419 



pedicle, which may subsequently form a hernia ; so, as in all abdom- 
inal operations, these patients should wear an abdominal pad and 
should be kept in bed not less than six weeks or two months after 
the operation. Occasionally, also, a fistulous opening may remain 
from the cervical canal to the incision, through which air may pass 
up and down on exertion ; this is, however, of rare occurrence, the 
greater danger being that of hernia. 

Intra-abdominal Method. — The patient is placed in Trendelenberg's 
position, the abdomen opened, and the tumor delivered if possible. 
If" this cannot be accomplished, the first steps of the operation are 
carried out with the tumor in situ. A single ligature is passed 
through the broad ligament near the pelvic wall and tied, not being 
passed deep enough to include the uterine arteries. Another lig- 
ature is made to transfix the broad ligament near the uterus, and 




Relation of the Ureters and Uterine Arteries to the Cervix: U, uterus: XJr, ureter; A U, uterine artery; 
C, cervix uteri, displayed by a transverse incision of the anterior vaginal cul-de-sac ; V, section nf the 
bladder at the level of the entrance of the ureters through its walls ; Vn, vagina : two bands of fibrous 
tissue are seen to unite it laterally with the uterus. We can distinguish in the cervix the part not 
covered by peritoneum which adhered to the bladder before dissection. 



tied. The tissue between these two li2:atures is cut throuj^h, and 
the same procedure is repeated on the opposite side. In this ma- 
neuvre the uterus is freed from its attachments to the pelvic wall, 



420 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

and the two ends of the ovarian vessels are safely included in the 
ligatures. The knife is now run lightly around the tumor an inch 
or two above the peritoneal reflexion of the bladder in front and 
a little lower behind, and the peritoneum stripped down, thus form- 
ing two flaps. The uterine arteries are next ligated as they pass 
between the cervix and the ureter, the ligature being passed close 
to the cervix, in order to avoid any possibility of including the 
ureter in its grasp. The ligatui'e may be passed between the flaps 
of peritoneum thus formed or outside of them. One is placed 
on each uterine artery and is securely fastened. This is the most 
important step in the operation. The tumor is now amputated at 
a level wdth the ligatures on the uterine arteries by a V-shaped 
incision, the point of the V being carried well below the point of 
ligation. The cervical canal is charred with a Paquelin cautery, in 
order to avoid any chance of septic infection from that source 
during the subsequent manipulations. The cervical flaps thus 
formed are now brought together with a continuous suture, which, 
after closing the cervix, is carried along, whipping the cut edges 
of peritoneum together from one side of the pelvis to the other. 
By this procedure the cervix, the two ligatures on the uterine 
arteries, and at times even the ligatures on the ovarian arteries, are 
turned under the peritoneum, thus becoming extraperitoneal. The 
abdomen is closed without drainage. 

There are three elements in this operation worthy of note : its 
bloodlessness without elastic temporary ligation, absence of raw 
surfaces from dissecting off the bladder, and avoidance of ligatures 
about the cervix, which tissue is free from the possibility of slough- 
ing. It has all the advantages, then, and none of the drawbacks, 
which attach to all other methods of treating the pedicle intra- 
abdominally. We believe it to be the ideal operation of its kind. 

When considering the intraperitoneal operation, and in view of 
the ease with which the vagina may be rendered sterile, the ques- 
tion naturally suggests itself, *' Why not go a little farther and 
remove the cervix too?" 

Total Abdominal Hysterectomy for Fibroid. — The patient is to 
be prepared as for both a vaginal hysterectomy and coeliotomy. 
Here, again, as many times before, stress is laid upon the import- 
ance of thoroughly cleansing the vagina and the difiiculty in doing 
so by the usual methods. Trendelenberg's posture occupies to this 
operation what Sims's does to vesico-vaginal fistula ; it renders the 



PLATE XXIV. 
Fig. 3. 




Fig. 4. 



Fig. 3.— Supra- vaginal Amputation of the Uterus : cervical canal being closed by sutures which are buried 
by subsequent sutures. 

Fig. 4.— Supra-vaginal Amputation of the Uterus : peritoneal edges of the stump in process of being 
whipped together, the lower stump being buried under the peritoneum. 



UTERINE NEOPLASMS. 



421 



operation not only possible, but comparatively easy. The patient 
is placed in Trendelenberg's posture. But two instruments need be 



Fig. 294. 





Deschamp's Needles. 



mentioned as supplementary to the ordinary ovariotomy set : blunt 
and sharp Deschamp's needles for ligating en masse. 

The typical operation will first be described, and then its appli- 



FiG. 295. 




Application of Ligatures in Ablation of the Fibroid Uterus : the broad ligament on the left side tied off 
in three tiers of ligatures, because of the presence of an intraligamentous nodule; on the right side 
the ligatures are applied in two tiers. 

cation under modifying circumstances. The objective points are 
the two ovarian and two uterine arteries, for these furnish the main 
blood-supply of the uterus and tumor. 



422 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

According to the size of the tumor must be the length of the 
incision. It is better to first make an incision equal to the appar- 
ent size of the tumor, than to be compelled to interrupt the regu- 
lar routine of the operation in order to enlarge an incision which 
at first was too small. 

The abdomen is opened and the relations of the tumor accu- 
rately determined. A large flat sponge or a thick broad pad of 
sterilized gauze is employed to keep the intestines away from the 
pelvic cavity and to catch any blood or discharges. This sponge 
or pad fills in the pelvic brim very much like a diaphragm, and 
not only catches fluid, but also protects the intestines from bruising 
and manipulation. The tumor is then eventrated, if this can be 
done without risk of tearing any of its attachments. The next step 
is to tie ofP the ovaries and tubes, thus securing the ovarian arteries. 
This is done by applying a double ligature through the broad ligament, 
near the uterus and below the tube, as in salpingo-oophorectomy. 
The two branches of these double ligatures are not to be crossed. 
The distal lio;ature on the broad lio-ament is first tied a little exte- 
rior to the ovary, and is cut short. The proximal ligature, crossing 
over the tube between the ovary and tumor, is next tied and cut 
short. Thus the tub* and ovary remain attached to the tumor, 
and the tissue of broad ligament between these two ligatures is cut. 
The preferable ligature material is large braided silk carefully ster- 
ilized, as it will stand great strain and does not attenuate in tying. 
These first ligatures having been applied on both sides, it will be 
found that the tumor can be lifted still further out of the pelvis. 
It is not necessary to amputate part of the tumor, and still less so 
to remove it in fragments by morcellation. Such proceeding but 
takes time and soils the field of operation. Two other double liga- 
tures are next applied, when necessary, from the overgrowth of the 
broad ligament — one set on each side, to secure the remaining part 
of the broad lio;ament down to the cervix at a level with the internal 
OS. The object of these ligatures is to include the excess of broad 
ligament without going too near the uterine arteries, which may 
easily be felt pulsating. When the tumor is small, and the broad 
ligaments not very deep, these middle ligatures may be dispensed 
with. They are applied as are the first, and the tissues between 
them are cut. We now have four double ligatures applied, two sets 
on each side, and the tissues severed between them down to the point 
of control of the lowest, at about the internal os. The uterus now 



PLATE XXV. 
Fig. I. 




Arterial Blood-supply of the Uterus and Adnexa: 0. A., ovarian artery; a', a', a', branches to ampulla of 
Fallopian tube; c\c\ c', branches to ovary; c, branch to fundus; rf, branch anastomosing with uterine; 
h, branch to round ligament ; e, uterine artery ; g, g, g, vaginal arteries ; b, b, azygos artery of vagina. 



Fig. 2. 




Venous Blood-supply of the Uterus: 5, uterine artery; c, vaginal artery. 



UTERINE NEOPLASMS. 423 

remains attached to the body only by the bladder and parametria] 
tissues. A semicircular incision is carried from side to side across 
the anterior face of the uterus, about half an inch above the vesico- 
uterine plica, extending through the serosa only. This membranous 
flap is dissected down with blunt scissors and the finger until the 
bladder is separated from the uterus and the vagina entered, care 
being taken to keep close to the uterine wall, lest the bladder be 
wounded. A guide in the vagina, as an assistant's finger, may be of 
service to the beginner in determining the position of the anterior 
vaginal fornix. Moderate filling of the bladder with urine or steril- 
ized water is of great advantage in rendering more apparent the 
relation of the bladder to tlie uterus, as this cannot so readily be 
distinguished when the walls of the bladder are collapsed. The 
operator's left index finger is now inserted into the space between 
the bladder and the uterus, and the vaginal rent is carried around 
the cervix a little way. But the surgeon must feel sure of his 
anatomy in doing so, lest he go too far and cut the uterine artery. 
Douglas's pouch is now opened, the finger in the vaginal rent acting 
as a guide to the posterior fornix, and at the same time an assistant 
tilts the uterus over the symphysis. The finger in the vagina and 
the thumb above, ov vice versa, the operator grasps between these 
two fingers a stout band of tissue in which the uterine artery may 
be felt pulsating. The Deschamp's needle is now passed, double- 
threaded of course, about a quarter of an inch from the cervix. 
The fingers so guide the direction of the needle that it does not 
enter the vagina, but is made to include all that mass of tissue 
between the last ligature applied above and down the vaginal 
mucous membrane, and between the anterior and posterior open- 
ings into the vagina. This ligature should comprise the uterine 
artery and its branches. The distal part of the ligature is now tied, 
and is left long. The other part is pulled close to the cervix and 
tied also, to control anastomotic bleeding from the tumor. The tis- 
sues between these two ligatures are cut, care being taken to leave 
an abundance of tissue to secure the distal ligature against slipping. 
Should there not be room enou2;h to tie the tissue with the double 
ligature, a single ligature may be passed to tie the distal part of the 
mass while the tumor side is grasped in forceps. The same maneu- 
vre is go.ne through with on the other side, and the mass is removed. 
But a single ligature applied to the distal end of the mass contain- 
ing the uterine artery will now sufiice, for there is no longer fear 



424 AN AMEBIC AN TEXT-BOOK OF GYNECOLOGY, « 

of anastomotic bleeding. If the uterine artery with its branches 
has been well secured by the last tier of ligatures, there can be no 
bleeding, except from small vesical branches anteriorly and from a 
branch of the middle hemorrhoidal in the posterior incision. These 
vessels are grasped and tied with fine silk or catgut. Usually two 
ligatures only are left long — namely, those on the uterine arteries. 
These are inverted into the vagina with the stumps which they 
include, and the pelvis is wiped free from blood and other dis- 
charges. The vagina is now snugly packed from above with iodo- 
form gauze to a point above the lowest stump. In this way the 
raw surfaces of the large stumps are kept apart and away from the 
intestines. Instead of the gauze packing, the edges of the vaginal 
mucous membrane may be whipped together by a continuous catgut 
suture, and over this the edges of the peritoneum should be simi- 
larly united, bringing down the stumps with the cervix, below the 
peritoneum. By this procedure subsequent attention to the wound 
is dispensed w^ith. The abdominal w^ound is closed and dressed in 
the usual manner, and an antiseptic pad put over the vulva. For 
a day or so the urine is drawn by a catheter. The bowels are 
moved in twenty-four hours by the use of salines in small doses 
frequently repeated. These may be supplemented by enemata. 
If gauze packing be used, the first dressing is made in a week — 
sooner if the temperature rises — and the change is made under 
irrigation by Thiersch's solution and the most careful asepsis. The 
vaginal opening above will be found closed by healthy granulat- 
ing lymph. The second vaginal dressing is made a week later, 
when with gentle traction the ligatures on the lower stumps will 
usually come away. Iodoform gauze dressings are inserted gently, 
so as not to disturb the granulations. If perfect asepsis is observed 
through both operation and treatments, the patients should be up in 
three weeks. 

Inasmuch as the vagina is entered in these cases, it must be 
rendered absolutely aseptic before the operation is begun. As many 
of the large tumors are subjected to various modes of intra-uterine 
treatment, including electricity, it is common to find them associated 
with purulent endometritis. It is useless to cleanse the vagina 
in such a case and leave the pus-focus ; disaster could but follow. 
Therefore it is advisable to curette the uterus some days before the 
coeliotomy is to be performed, removing the first dressing the day of 
the operation when the vagina is cleansed, or the uterus may be 



13 




UTERINE NEOPLASMS. 



425 



tightly packed with iodoform gauze the day of the operation. If 
a curettage is done, the uterus should be washed out when the 
dressing is removed. 

Intraligamentous (Dumb-bell) Fibroids. 

Fibroids dissecting into the broad ligament, posteriorly beneath 
the peritoneal folds of Douglas's cul-de-sac, anteriorly into the 
bladder, or laterally toward the pelvic walls, are the most formid- 
able growths the surgeon meets. They are not amenable to the 
tardy benefits to be derived from medicinal treatment or the opera- 
tion of salpingo-oophorectomy. There being no possibility of a 
pedicle, they cannot be removed by supravaginal amputation. 

Fig. 296. 




Intraligamentous Fibroma : A, abdominal variety ; B, pelvic variety. 

They can be removed by but two procedures : either by total 
extirpation or by the intra-abdominal method. 

The operation is begun as for the typical extirpation. The liga- 
tures on the ovaries and tubes are applied as in the operation just 
described. Should the tumor project between the folds of the broad 
ligament on ona side only, or otherwise so grow as to leave one side 
of the pelvis free from the tumor, the operation is completed on 
the unaffected side first ; that is, after the first ligature on the ovary 
and tube has been applied, the middle ligatures are passed and tied, 
and then those around the uterine artery as in the typical operation. 



426 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

If the total extirpation be chosen, the vagina is now entered, prefer- 
ably by first dissecting away the bladder, or, if that be too difficult, 
the vagina may first be opened through Douglas's cul-de-sac, an 
assistant's finger in the posterior fornix acting as a guide. This 
procedure enacted, the mass is rendered much more movable and 
more easily in command of the operator. The relations of the 
intraligamentous tumor having been accurately determined, the 
capsule over the growth is split in such a way as to avoid wound- 
ing any important structure, and, if possible, avoiding the large 
venous sinuses which always cover these growths, the cut in the 
capsule being so made as to afford two large flaps, if possible, 
of equal size. The tumor is now dug from between the layers of 
the broad ligament, or from under the post-uterine peritoneum, or 
away from other attachments which it may have, care being taken 
to keep close to the tumor in doing this. If the tumor grows pos- 
teriorly, there is great danger of wounding the bowel ; if it grows 
to one side or into the broad ligament, the pelvic floor on that 
side will be stripped, and the ureter or important vessels may be 
wounded ; when bulging in front into the bladder space, that viscus 
is in danger of injury. 

It is impossible to describe the appearance of the vessels sur- 
rounding these tumors : they are huge sinuses. The capsule having 
been carefully dissected away from the tumor, and with as little 
bleeding as possible, we approach a point at which the uterine 
artery enters the growth. After the capsule is incised all efforts 
at enucleation should be made with blunt instruments or pref- 
erably with the fingers. This enucleation is done in a direction 
from without inward toward the uterus. 

The assistant lifts the tumor as high as possible, putting the 
remaining band of tissue on the stretch. The operator, with one 
finger in the vaginal rent to the side of the cervix near the tumor, 
passes a sharp Deschamp's needle, double-threaded, through the 
centre of the remaining attachments of the uterus from above down- 
ward. Entering the vagina, the loop of the ligature is caught with 
the finger in the vagina and the needle withdrawn. The loop is 
then cut, forming two separate ligatures, one of which is brought 
anteriorly, and the other posteriorly to the side of the cervix. 
They are both tied, without being crossed, and left long. Both 
are distal ligatures, and include within their grasp all the remain- 



PLATE XXVII. 
Fig. 2. 




Fig. 3. 



Fig. 2.— Total Abdominal Hysterectomy: second step. Vagina opened anteriorly, with the index finger in 
the vagina, while the ligature is being placed about the uterine artery. 

Fig. 3. — Total Abdominal Hysterectomy : ovarian and uterine arteries ligated and uterus removed, leaving 
the vaginal vault opened. 



UTERINE NEOPLASMS. 427 

ing tissues which contain blood-vessels. The tissues are now cut 
between these ligatures and the tumor and cervix removed. 

If there be no part of the lateral pelvic wall free from tumor, 
the ovaries and tubes of both sides are first tied off; then the 
capsule over the smaller lateral nodule is incised, and enucleation 
made up to the point of reaching the uterine artery. Douglas's 
cul-de-sac is opened, or the vagina entered from the bladder side, 
if that be possible, and the double-threaded Deschamp's needle 
passed as in the last step of the previous operation. The two 
ligatures are tied as distal ligatures, and the tissue close to the cer- 
vix grasped with forceps ; the tissue between the ligature and for- 
ceps is then cut, great care being taken to leave an abundance of 
tissue in the grasp of the ligatures to prevent their slipping. The 
forceps are for the purpose of controlling anastomotic bleeding. 

The rest of the operation is completed as when one side of the 
pelvis is uninvaded. The excess of peritoneal flaps is cut away, 
and their edges approximated accurately by sutures of running cat- 
gut. The ligatures in all these operations for intraligamentous 
fibroids are inverted into the vagina with the stumps they included, 
and the vagina is packed with iodoform gauze as in the typical 
operation ; the packing extending, however, to the top of the 
cavities left from enucleation, thus securing perfect drainage of all 
raw surfaces. The caution is necessary in incising the capsule that 
a displaced ureter be not cut, as this tube sometimes lies on top of 
the capsule. The great rule in the enucleation is to keep close to 
the tumor and avoid any injury to the capsule near its base or outer 
extremity. All these tumors growing between or under the peri- 
toneal planes must be operated upon with the object solely of con- 
trolling hemorrhage before cutting is done. The same small vessels 
are met with here in the anterior and posterior flaps as in the 
typical operation. Cleansing of the pelvis and other procedures 
are as in the typical operation. 

The statement has been made that this operation of total extirpa- 
tion weakens the pelvic floor and contributes to hernia through the 
vagina. This is purely theoretical. Such an accident is not known 
to follow total vaginal hysterectomy of the cancerous uterus, and it 
has not been observed as a result of extirpation of the fibroid organ 
by coeliotomy. Shortening of the vagina, however, takes place. 

If the intra-abdominal method be chosen for the removal of 
these tumors, the steps are the same as above until the pelvic floor 



428 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

is reached, and then the subsequent steps are made according to the 
description under the Intra-abdominal Method. 

Complications met during the Operation. — Adhesions may be 
entirely absent with the largest tumors, and, conversely, small 
tumors may present the most firm adhesions to important structures. 
They may attach the growth to any of the pelvic and abdominal 
contents, and are invariably of inflammatory origin. The adhe- 
sions are of two kinds, occurring as longer or shorter bands or as a 
close union between broadly adjacent surfaces. Bands are sparsely 
supplied with blood, but unions by broad attachment are very 

Fjg. 297. 




Suture of the Thin Fold of Peritoneum and Fibrous Tissue left after the Detachment of a Firm Adhesion 
from the intestine : I, intestine ; P, peritoneal fold covering the fibroid ; S, suture. 

vascular. It occasionally happens that the fibroid will derive its 
main blood-supply from an adventitious adhesion. This is espe- 
cially the case where subserous fibroids are attached to the 
omentum. 

Band-like adhesions not very vascular may be torn with the 
fingers or by scissors. Those which are vascular must be cut 
between two ligatures. Separation of the adhesions when broad 
must be made at the expense of the tumor, and not of the tissue to 
which it grows. This is pre-eminently the rule when the tumor is 
closely adherent to the gut. 

Adhesions are most general and firm when there have been 
former attacks of peritonitis. And it is the very general opinion 
among surgeons that electricity, whether applied intra-uterine or 
by galvano-puncture, even though there be produced thereby no 
apparently distinct attack of peritonitis, yet tends to cause the most 
firm and embarrassing adhesions between the tumor, parietes, and 
viscera. Usually, however, the electrical current in strengths 
advocated for the relief of hemorrhage or the reduction of a fibroid 



PLATE XXVIII. 
Fig. 4. 




Fig. 5. 



Fig. 4.— Total Abdominal Hysterectomy: vaginal vault in process of closure, Avith lower stumps 
drawn into the vagina. Opening in the left broad ligament closed. 

Fig. 5.— Total Abdominal Hysterectomy : stump drawn into the vagina, and vaginal opening 
packed with gauze. 



UTERINE NEOPLASMS. 429 

will produce distinct peritonitic iDflammation. It is always a matter 
of regret to the surgeon that a case to be subjected to the radical 
operation has previously been in the hands of the electrician, for 
he knows from experience that it is just such which present the 
greatest complications. 

Tubal and Ovarian Disease — Very commonly, hypertrophic sal- 
pingitis and chronic oophoritis are associated with fibroid tumors. 
But inflammatory lesions of tubes and ovaries are generally due to 
a septic or specific endometritis. As frequently producing such 
changes in the endometrium are the various means applied for the 
relief of hemorrhage and attempts at reduction of the tumor. Such 
are filthy curettements, injections of astringents, and electricity. In 
other words, here more than in the uterus not the seat of neoplasm 
do we find improper intra-uterine manipulations one of the causes 
of complications in the adnexa or peritoneum. Milder degrees of 
tubal inflammation may result in occlusion only, thus producing 
hydrosalpinx. 

It must not be forgotten that fibroid may exist coincidently with 
ovarian cystoma. Pus- tubes or ovaries should, if possible, be 
removed before the extirpation be begun. But cases do occur where 
the extirpation must first be made, the pus-focus being tied ofl" from 
the tumor and enucleated as a last step. 

In such cases the gauze packing must extend to the denuded sur- 
face produced by the removal of the pus-focus. 

General Considerations. — The treatment to be selected for each 
case must not be determined by the character of the tumor alone. 
Other considerations are to be entertained before arriving at the final 
conclusion. A patient who is in" easy circumstances, who can 
afford idleness, and can secure comforts may well spare a few months 
of her life devoted solely to the effort of getting well by palliative 
and mild methods. The poor woman, a burden to her friends and 
unable even to secure necessary physical rest, will demand a meas- 
ure which is radical. The general physical condition of a patient 
will determine the character of the operation more than any other one 
thing. An exsanguinated woman who is in good flesh will stand a 
long operation very well, but it is different with those who have large 
tumors or other tumors producing pressure symptoms. Apart from 
the possibility of liver and kidney complications, these latter women 
suffer from a form of heart degeneration which renders prolonged 
narcosis dangerous ; this is especially so, if there be kidney disease. 



430 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Therefore it may be that many of the radical procedures would 
waste valuable time, and the most rapid method must be employed, 
even though it be incomplete. In any case where radical operation 
is indicated total extirpation can be as rapidly and safely performed 
as that particular procedure which seems especially applicable. In 
skilful hands it does not take longer to extirpate the entire uterus 
than to properly attend to the stump by the various other methods. 
Tumors characterized by profuse hemorrhage should be removed 
by total extirpation. Total extirpation is applicable to every variety 
of tumor. Some of the other methods have limitations, and tliere 
are certain tumors not amenable to each operation. 

Suprapubic amputation is not to be applied to virgins who have 
very short vaginae, to fibroids which dissect into the broad liga- 
ments', ta those which burrow into the floor of the pelvis, and to 
those which already are septic. Hegar's or Tait's operation of 
removal of the adnexa to induce artificial menopause and cut off 
part of the blood-supply has produced results which command our 
most careful attention. That it will check the growth of some 
tumors, and often cause them ultimately to disappear, is undoubted. 
But it is not immediate in its effect on the size of the growth, though 
'the hemorrhages may cease at once. Therefore those tumors which 
have dangerous or very painful pressure effects demand a more 
radical procedure. It is hard to say just when the operation should 
be applied to the exclusion of all others. For tumors which respond 
most readily to this treatment also give the best results from a radical 
operation. Certain interstitial and subserous tumors require the 
greatest skill in their removal. In certain rare cases of intralig- 
amentous growths, and in patients who will not bear a radical ope- 
ration, we would suggest the salpingo-oophorectomy. Tumors of 
the soft, oedematous, fibro-cystic variety are but little, if at all, influ- 
enced by this operation. It is, then, limited to cases of hard myo- 
fibromata, and chiefly to those in women under thirty-five — the very 
cases giving the best results from total extirpation. It must 
undoubtedly be considered an incomplete operation with a limited 
application. For the natural menopause does not often come on in 
the presence of fibroid. In fact, the latter continues the bleedings 
indefinitely. Tying off the ovaries and tubes, then, very often 
utterly fails in stopping the bleedings, for the operation merely 
removes the least factor in the causation of the hemorrhage, the 
adnexa. It does limit the bleeding somewhat in all cases by cut- 



PLATE XXIX. 



i\«>5!R^ 




Intraligamentous Fibroid Tumor of the Uterus with Hydrosalpinx, showing the portions of the tumor 
which were buried under the peritoneum in the connective tissue: front and hack views. 



UTERINE NEOPLASMS, 431 

ting off the blood-supply through the two ovarian arteries, and 
removal of the adnexa takes away the stimulus to menstruation. 
But the perverted and pathological function has usually gone too 
far to be controlled by such mild means. 

In his last work Tait quotes 262 cases with 4 deaths — 1.5 per 
cent, mortality, about that incident to the electrical treatment, with 
vastly less suffering, much better results, and less injury to the 
woman in case the operation fails and a radical one becomes neces- 
sary. But these figures are for uncomplicated cases of fibromyoma. 

We would, then, summarize the treatment of fibroids about as 
follows : Small submucous fibroids which can readily be removed 
per vaginam should be subjected to that method. All others demand 
different procedures. 

The patient's general condition and the character of the tumor 
would determine whether or not to operate. Those cases in which 
the decision is against operation should be treated by ergot. 

An operation deemed advisable, in all cases the total extirpation 
is indicated to the exclusion of every other operation, unless there 
be some special indication against it. There are no special objec- 
tions to substituting the intra-abdominal method, it being in all 
essential respects a total extirpation, provided there is absolutely 
no possibility of cancer in the tissues of the cervix left by the 
operation. 

The intra-abdominal methods of Zweifel and Schroeder are no 
longer necessary. The great leap has been from the extraperito- 
neal operation to the complete extirpation. And at the same time 
we leave a partial operation with a tedious convalescence, adhesions 
about the stump, and possibly hernia, for a complete operation, with 
a mortality less than 8 per cent, in the worst kind of cases, and no 
disagreeable sequelae. In selected cases which have escaped electri- 
city and other intra-uterine treatment the mortality should be not 
more than 3 per cent. 

Causes of Death after Coeliotomy for Fihro-myomata. — Hemor- 
rhage after the intraperitoneal method is the immediate danger. It 
is presumed that the surgeon will not close the abdomen until all 
oozing has been controlled. Therefore secondary hemorrhage is 
the one to fear. The patient has sudden pallor without assignable 
cause. The pulse becomes rapid and small. There is an anxious 
expression about the face ; cold sweat covers the body and the tem- 
perature becomes subnormal. The patient should at once be put 



432 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

into Trendelenberg's posture, so that auto-transfusion from the 
lower parts of the body to the chest may be thereby performed. 
This procedure also limits the amount of bleeding markedly. 
Cutaneous transfusion of sterilized salt solution into the scapular 
regions, along the borders of the latissimus dorsi muscle, should be 
employed, while preparations are making to reopen the belly. 
We cannot speak too higiily of Trendelenberg's position in all 
cases of bleeding from the pelvic floor. Examination is of no 
aid to us in these cases unless the bleeding takes place into the 
broad ligament, and even then it may have formed there immedi- 
ately after the operation. Blood escaping into the pelvic peritoneal 
cavity does not coagulate for many hours, and gives us no signs of 
its presence while in a fluid state. Bleeding from the extra-perito- 
neal pedicle is readily detected. If it occurs from the breaking of 
an elastic ligature, a Koeberle's ecraseur should at once be thrown 
around the stump. Bleeding after the intra-abdominal operation 
will show from the vagina. The same is true when bleeding fol- 
lows extirpation of the entire organ, unless the leak be from the 
ovarian arteries. 

Sepsis. — This now may be very well controlled, inasmuch as not 
one death in five is due to it after extirpation. 

Temperature after extirpation is not usual, and must give rise to 
grave suspicions of the technique. It may be produced by tympan- 
ites, by incomplete preparation of the patient's bowels, by diseases 
of the liver and kidneys. It is therefore imperatively necessary to 
open the bowels the day after the operation, or just as soon as the 
ether nausea has passed ofl*, allowing the stomach to retain the salts. 
Twenty grains of Bochelle salts every half hour, for from four to 
eight doses, will accomplish the desired result. Purgatives contain- 
ing calomel may be tried if the stomach be particularly irritable. 
Triturates of calomel, one-half of a grain, with aloin, one-eighth 
of a grain, may be given. Two doses, two hours apart, will suffice. 

When a case becomes septic after the extra-peritoneal treatment, 
careful scrutiny of the stump and wound should be made for pock- 
ets of pus. If the sepsis arises from intra-abdominal causes, 
secondary laparotomy is about useless, but may be tried as a last 
resort. 

Sepsis after the intra-abdominal method occupies the same posi- 
tion unless localized around the stump, when the pus may be evac- 
uated from the vagina. 



UTERINE NEOPLASMS. 433 

If sepsis occurs after total extirpation, the vaginal dressing should 
be removed and the stumps and vaginal vault examined. Any pus- 
focus in the pelvis can thus be detected and drained. Should it be 
deemed wise to go further and again open up the abdominal cavity, 
it may be done without narcosis by using the finger in the vagina 
to break up the lymph union. This having been done, the pelvis 
should be irrigated with Thiersch's solution, and the gauze packing 
again introduced from below to fill if possible the pelvis. 

Shock. — In the greater number of cases of this condition hem- 
orrhage has taken place. The narcosis may prove too much for the 
patient, inasmuch as brown and fatty heart degeneration is a frequent 
result of fibromata, and she may die from heart failure. In this 
condition hypodermics of nitro-glycerin, yw grain, with rectal injec- 
tions of rye whiskey, one part to four of warm milk, are indicated. 
The nitro-glycerin is a powerful heart tonic, and may not be 
repeated more often than once in three hours. Strychnia is useful 
as a substitute for nitro-glycerin when it is desired to stop the use 
of the latter. Prolonged exposure and rough handling of the 
viscera are conducive to shock and must be avoided. They are 
minimized by the use of Trendelenberg's position. 

Intedinal Paralysis. — After the removal of large fibroids, and 
also, occasionally, when moderate-sized interstitial growths are re- 
moved, a condition which has been termed intestinal paralysis may 
ensue. It is characterized by a cessation of the normal peristalsis 
of the intestines. It depends upon one or both of two causes — the 
sudden relief of the intra-abdominal pressure by removing a large 
growth, thus allowing the intestines to become engorged with blood, 
and the shock to the sympathetic system from the removal of an 
organ so intimately connected with it as is the uterus. To lessen 
the flux of blood to the abdomen after the wound is closed, a large 
elastic abdominal dressing of dry cotton should be so applied as to 
exercise a pressure over the whole abdomen. To lessen the shock to 
the sympathetic, the administration of strychnia in 4V gr. doses, three 
times a day, should be begun a week before the operation. This 
intestinal paralysis is characterized by inability to move the bowels 
by the ordinary means, by tympanites, and in a few days by tem- 
perature if the tympanites be excessive. If, then, we give opium 
to these cases, it merely contributes to the supervention of the very 
condition we wish to avoid. Calomel gr. \ triturated with aloin 
gr. i every hour until five doses are taken, followed. If necessary, 

28 



434 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

in six hours bj a high enema — an enema extending to the upper 
part of the descending colon, of Kochelle salts one ounce in a quart 
of water — will usually suffice. The combination of calomel and 
aloin is recommended as producing a more free outpouring of bile, 
which is the best excitant of peristalsis. 

This paralysis of the bowels has often been confounded with 
intestinal obstruction and sepsis. The differentiation is difficult. 
In sepsis the first symptoms are fever and high pulse-rate, whereas 
these occur later in intestinal paralysis. Intestinal obstruction pro- 
duces pain at the seat of obstruction in addition to the other symp- 
toms of reversed peristalsis, as fecal vomiting. 

During the operation certain accidents may happen. Wounds 
in the intestine should be immediately closed by silk sutures, 
applied in two tiers. Should so large a portion of gut be torn out 
as to render obstruction probable if the rent be closed, it is neces- 
sary to fasten the opening into the abdominal wound, forming an arti- 
ficial anus, or to make an anastomosis. Openings into the colon are 
to be treated in the same way. If the rectum be entered, it is neces- 
sary to close the opening as well as possible, and to employ a gauze 
packing of the pelvis so as to form a fecal fistula in case the sutur- 
ing of the opening in the bowel should separate. Experience and 
the use of Trendelenberg's position will render such accidents rare. 
If extirpation has been performed in such a case, through and through 
drainage from abdomen to vagina with gauze is necessary, the two 
packings meeting at the fistula. In all these cases where the rectum 
is wounded the pelvis must he filled with gauze, thus keeping all the 
intestines in the general abdominal cavity. A wall of lymph will 
then form and cover over the pelvis entirely, so that the field of 
surgical interference and injury is entirely shut off from the gen- 
eral peritoneal cavity. When the rectum is wounded, the sphincter 
ani should be widely dilated and a large short tube introduced, so 
as to give free vent to intestinal gases. 

Adherent omentum may be tied off en masse by a double 
ligature. 

Injury to the bladder is not serious. The wound should always 
be closed by silk, catgut being too unstable. After injuries to the 
bladder a permanent catheter should be left in position for four 
days and carefully watched to see that it does not become clogged. 
It should be removed each day to be cleansed, and immediately 



UTERINE NEOPLASM8. 435 

reintroduced. Injury to the bladder is best avoided by having it 
moderately distended, so that its contour is easily recognized. 

Wounds of the ureter will be accompanied by the passage of 
decreased quantities of urine, and that drawn from the bladder 
will be found microscopically to contain red blood-corpuscles. 

If the ureter be wounded during the operation, the outlook for 
the patient varies in accordance with the position of the injury. If 
the injury be near the floor of the pelvis, the ureter may by careful 
dissection be separated and sutured into the vagina or the bladder. 
If the wound be high up, the kidney of that side may be removed, 
or, preferably, the ureter may be sewed into the abdominal wound. 
If both rectum and ureter are wounded, the ureter should be fast- 
ened in the rectal wound after the tumor is extirpated. 

If the patient survives such an accident, the consideration of 
extirpation of the kidney or other procedure will arise. 

These operations should be performed as rapidly as is possible 
without interfering with the technique of the method. 

Total extirpation is merely the application of Freund's operation 
to the treatment of fibroid. 

The credit for this application is due to Bardenhauer of Cologne. 
Following him in Europe was Martin. In America, Eastman first 
performed the operation by a rather complicated technique. To 
Krug belongs the credit of perfecting a method by which the ope- 
ration may be rapidly and easily done, the essential features of 
which are the use of Trendelenberg's position and the severing of 
the tissues under the guidance of the eye. 

The method of total extirpation here described is practically 
that first published by Krug. 

The operation has been given much prominence and has been 
advised to the exclusion of all other radical measures because it has 
been employed in the greatest possible range of difiicult cases. In 
one city alone the operation has been done fifty times with four 
deaths — a mortality of 8 per cent. Many of the cases so operated 
upon were refused admittance to several hospitals as being inope- 
rable. 

Salpingo- oophorectomy for Fibroid. — This is sometimes exceed- 
ingly difficult, owing to the tumor pinning one ovary and tube deep 
in the pelvis. Should this be the case, an assistant should attempt 
with the hand in the vagina to raise the entire mass from the pelvis. 
The ovary and tube having been found, the blunt Deschamp's 



436 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

needle should be passed as close to the uterus as possible without 
wounding the anastomotic coil between the ovarian and uterine 
arteries. One ligature is then tied very close to the cornu, so as to 
include the sympathetic nerve of the tube, and the broad ligament 
is tied below the ovary. Both are then removed. The ordinary 
locked suture is employed. It is not necessary to use the Paquelin 
cautery. 

Sometimes also the tumor so grows beneath the ovary and tube 
that these are spread out over its surface and merely form part of 
its serous capsule. Their removal is here impossible. The ope- 
ration is not applicable to fibro-cysts ; it controls hemorrhage in 
about three-fourths of the cases, causing rapid diminution in the 
size of the organ in about three-fifths, and, excepting Tait's 
unequalled figures, has a mortality of 5 per cent. His results 
are only for removal of uncomplicated, non-suppurating ovaries, 
and tubes ; he reports 262 cases with 4 deaths. 

The operation is only applicable to small pelvic growths and to 
such of these as have appendages which can be easily removed ; 
otherwise hysterectomy is preferable. 



PELVIC INFLAMMATION. 



It is intended to include under this heading all those pelvic 
inflammatory diseases which involve the Fallopian tubes, the ovaries, 
the pelvic peritoneum, and the pelvic cellular tissue — all those con- 
ditions described by the terms salpingitis, pyosalpinx, ovarian 
abscess, perimetritis, parametritis, peri-uterine phlegmon, pelvic 
abscess, pelvic cellulitis, pelvic peritonitis. These conditions are 
so intimately associated and so constantly complicate each other that 
it becomes impossible to treat of one without taking into consider- 
ation several or more of the others. Rarely does a pyosalpinx 
exist except it be complicated by a pelvic peritonitis, and in all 
probability a pelvic cellulitis, the peritonitis and cellulitis arising 
from the same source as the salpingitis, and not being independent 
lesions. The abscesses, for the most part, are results of the more 
advanced stages of these same conditions, and in themselves rarely 
exist as independent factors. It is hard to study these inflammatory 
productions without seeing a direct line of cause and effect. With 
our present knowledge of these matters it is no difficult thing to 
trace the infection from its inception, and to recognize its course in 
the lesions left behind as it pursues its destructive way. 

It is our purpose, then, to deal with this subject as though it 
were a single disease — as in fact and in truth it is — and of each of the 
resultant factors as simply the same disease attacking, in its progress, 
the different anatomical portions of the female pelvis, leaving in 
each locality an apparently different and independent lesion, the 
lesion differing in accordance with the structure attacked, with the 
severity of the attack, and with the stage at which the progress of 
the disease has been stayed. It were just as rational to consider the 
peritonitis, the cellulitis, and the abscesses complicating an appendi- 
citis as independent of the inflammation of the appendix as to sep- 
arate these same conditions from the salpingitis. In the case of the 
appendicitis the infection comes from inside the appendix, and, 

437 



438 AN AMEBIC AN TEXT-BOOK OF GYNECOLOGY. 

having passed through its walls, attacks first the peritoneum, and 
secondly the cellular tissue. 

In the same manner does the infection which destroys the pelvis 
come from the Fallopian tube, only, instead of being compelled to 
pass through the walls of this organ, it the more readily finds its 
way through the fimbriated opening directly into the peritoneal 
cavity and secondarily into the connective tissue. The amount of 
destruction accomplished will of course be in direct relation to the 
severity of the infection. Some attacks will not proceed further 
than the Fallopian tube itself, and often end even there without sup- 
puration. The inflammatory process may extend into the peritoneal 
cavity and confine its ravages to the peritoneum itself, or it may 
extend deeply enough to involve the cellular tissue, causing it to 
break down and suppurate. The reason these differences exist in 
individual cases is only to be explained by the character of the 
infection and its virulence. At times two given cases will not 
progress in exactly the same manner, even where the origin has 
been the same. Some local condition may exist so as to materially 
modify the course of the disease in the one case, while the other one 
may proceed rapidly to an amount of destruction which can never 
be repaired, if not unto death itself. When it is fully realized that 
this whole group of diseases originates from a common point and 
from a limited variety of infections, the importance of a careful 
study and understanding of these becomes at once apparent. 

Inflammations of the female pelvis and pelvic organs constitute 
a very large proportion of the diseases of women. They are the 
most destructive and dangerous, as well as the most incurable, cases 
that the physician has to treat, provided they once gain headway or 
have accomplished their ravages before they come under observation. 
At the same time, taken in their incipiency, they are readily retarded 
and cured. As in all other conditions, where it can be accomplished 
it is much easier to prevent the subsequent ravages of the inflam- 
mation than to cure the resultant lesions. As a rule, after the fire 
has once swept over its course such destruction has resulted that a 
cure short of surgical methods is out of the question, and at times 
even these are unavailing. Once allow a woman to contract pelvic 
inflammation with all its possibilities, and allow the disease to run 
into a chronic condition, the chances are that she will have acquired 
such a degree of invalidism as to feel the results for the rest of her 
life, even though the disease be removed. Many of these women 



PELVIC INFLAMMATION, 439 

never, under the most favorable circumstances, regain their former 
state of health. 

Causation. — Pelvic inflammations arise almost without excep- 
tion from either septic or specific infection. The exceptions are 
those rare cases in which the disease has had its origin in a sudden 
suppression of menstruation or where it is due to the irritation of 
neoplasms, such as fibroid tumors and ovarian cysts. Even in these 
exceptions it becomes a question at times whether or not the peri- 
tonitis, be it acute, has not originated from septic material contained 
in a diseased Fallopian tube or ovary. Chronic inflammation may 
be readily engendered by the irritation due to the presence of an 
abnormal growth in the pelvic cavity, but such a process seldom 
brings about such disastrous results as do the acute inflammatory 
attacks. The changes here are more of a gradual thickening and 
hypertrophy of the epithelial and interstitial elements, and there is 
little or no danger of resultant adhesions or abscesses. A very 
great many neoplasms are complicated by disease of the Fallopian 
tube. It is obvious what chances there are of a leakage of infective 
material from an enlarged and diseased tube. Even where there is 
no leakage through the fimbriated end, or no rupture of the walls 
of the organ, yet it is a well-known fact that the peritoneum about 
these members is peculiarly liable to attacks of inflammation, prob- 
ably by extension of the disease directly through their walls. Any 
given case of pelvic inflammation complicating the growth of a 
neoplasm is always open to the just suspicion that there is, in addi- 
tion to the new growth, a lurking infection in the Fallopian tube. 
In such a case the cause of the inflammation would again be sought 
in a septic or specific poison, brought about in much the same man- 
ner as are the vast majority of cases of pelvic inflammation. It is 
well known that the rupture of some cystic tumor, and the empty- 
ing of part or all of its contents into the abdomen, may give rise to 
this same character of trouble. These cases are, however, the excep- 
tion, and usually, when they do occur, it is not difficult to differentiate 
them. Those cases which are apparently due to the traumatism inci- 
dent to operations, the use of the uterine sound, the introduction of 
sponge tents, and other similar procedures are beyond doubt caused 
by the addition of septic poison to the traumatisms, and not to the 
mere wounds themselves. Careful use of ordinary antiseptic precau- 
tions will obviate any chance of such mishaps. If a patient be 
suffering from venereal disease, and a solution of continuity of the 



440 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

mucous membrane, either of the vagina or uterus, be made in the 
course of an operation or an examination, it is hardly to be expected 
that there shall be a universal escape from some of the disasters of 
a spread of the infection into the connective tissues through the 
open wounds so made. 

If, however, the disease be cured prior to an attempt at operative 
procedures, or even if great care has been taken to disinfect the 
parts to be operated upon, the chances of infection are minimized. 
The same may be said of infection carried by dirty instruments 
during the course of an examination. It is extremely problematic 
whether or not many cases have resulted from such sources where 
even the most ordinary care has been taken with the implements 
used. A speculum or a pair of dressing forceps must be noticeably 
dirty to carry infection from one patient to another, particularly 
if the mucous membrane of the vagina be reasonably sound and 
healthy. The danger resulting from the use of a sponge tent is 
likewise due to a septic condition of the tent or of the vaginal or 
uterine canals. And so with most other instruments usually held 
accountable for the origin of pelvic inflammations. As in the case 
of neoplasms, so in all cases that require the use of instruments, it 
is far more likely that there is already existing the source of infec- 
tion in the Fallopian tubes, ovaries, or peritoneum than that the 
use of these instruments has originated the attack. If a woman 
has a diseased and possibly adherent Fallopian tube, especially if 
it be distended with pus, any manipulative interference will surely 
tend to relight an inflammation which had become quiescent, and 
had probably remained so for years. If the disease be originated 
by the mere use of the instrument, it is almost certainly not due to 
the introduction of septic or specific poison as an additional element 
in the case. It is problematic whether traumatism per se ever orig- 
inates pelvic inflammation. The peritonitis due to sudden suppres- 
sion of menstruation does not, as a rule, leave behind it any such 
traces as are left after an attack of septic peritonitis. The inflam- 
mation is of a frank, open character, without usually any tendencies 
to the exudation of plastic lymph, such as will not subsequently be 
absorbed. When such an attack has cleared up, there are left no 
microscopic lesions, except it be in the ovary itself, and here the 
changes are more likely to be of an interstitial character, such as 
follow chronic inflammation in these organs. Frequently these 
attacks do not amount to anything more than a severe congestion. 



PELVIC INFLAMMATION. 441 

stopping short of true inflammation, rest in bed and depletion 
accomplishing a speedy and permanent cure. Pelvic peritonitis 
caused by venereal excess, independent of any other factor, is more 
than doubtful. The traumatism, it is true, incident to such excess 
would tend to foster such a result, but the continued relief from 
congestion due to the repeated normal terminations of coition would 
tend to promote anemia of the parts rather than congestion. As in 
the ca»e of many other supposed causes, a previously diseased condi- 
tion of the uterus or uterine appendages is in all probability at the 
bottom of the trouble, in which case it is easy to understand how the 
incidental and repeated traumatism would bring about the result. 

Septic or specific infection of the genital canal is the cause of the 
vast majority of pelvic inflammations. Septic infection enters in 
one of two ways : either through wounds caused by operations 
(the use of tents, the use of the uterine sounds, specula, and other 
instruments) or through the wounds caused by childbearing and 
abortion. 

Puerperal septicemia outweighs by far all the other sources of 
septic trouble, and compared with this source the others are practi- 
<3ally nil. Puerperal septicemia rivals, and even exceeds, gonorrhea 
as an etiological factor in these diseases. The analysis made by Ber- 
nutz of 99 cases of pelvic peritonitis shows at a glance the two great 
factors in the production of pelvic inflammatory troubles : 

43 occurred in puerperse ; 

28 " after gonorrhea ; 

20 " during menstruation. 

f 3 due to venereal excess ; 
. J 2 " syphilitic disease of the cervix ; 

I 2 " introduction of the uterine sound ; 

Ll " use of the vaginal douche. 

This table is susceptible of considerable modification, and if the 
whole truth were known it is more than probable that every 
case in it could have been traced to gonorrhea or post-puerperal 
septicemia had as much been known of these troubles in the 
time when the cases were tabulated as is known about them at 
the present time. It is more than probable that in every one of 
the 8 traumatic cases and in the 20 recorded as occurring during 
menstruation, there was present a pre-existing inflammatory disease 
in the pelvis which was only awaiting some favorable opportunity to 



442 ^iV^ AMERICAN TEXT-BOOK OF GYNECOLOGY. 

develop. That twenty of the attacks took place during the men- 
strual period is only what could be expected. At this time there is 
a natural congestion of the pelvic organs; this congestion, added to 
the already existing inflammation, latent perhaps, but none the less 
real, would place the patient in the best possible condition for any 
outside influence to determine the resulting acute attack of pelvic 
inflammation. Forty-three of the cases are recorded as occurring 
in puerperse, and twenty-eight after gonorrhea. A second glance 
is convincing that in all probability a few of the puerperal cases 
were caused by gonorrheal infection — -just what proportion it is 
impossible to tell. The argument might, in fact, be brought to 
bear in every case of post-puerperal septicemia, that the woman had 
previously been infected with gonorrhea, else she would not have 
developed the puerperal disease. Such is undoubtedly the case in 
many instances, but, in spite of the great possibility of such an 
occurrence, there is yet a large proportion of cases which undoubt- 
edly arise from a puerperal septicemia, entirely independent of 
venereal contamination; the proportion is fully as large as in 
that class where the cause is unquestionably gonorrhea. This 
is even true of many of those women whose husbands have per- 
chance contracted a gonorrhea in their younger days before 
marriage. Because a man has once been afflicted with venereal 
contamination, it by no means follows that he always retains the 
disease, as has been contended by some writers, and that he is sure 
to contaminate any woman with whom he has intercourse. Whether 
or not the gonococcus is the cause of gonorrhea, it is notorious that 
many discharges contain this factor without being able to reproduce 
the disease. It has been shown also that it is not possible to infect 
the healthy mucous membranes with the discharges from some cases 
of chronic gleet. On the other hand, experiments have been pro- 
duced to show that quite the reverse of this is true. However this 
may be from an experimental point of view, certainly the relation 
of cause and effect in such a case as the following is apparent: 
A young and healthy woman is married to a man who had con- 
tracted gonorrhea some time previous to their marriage, but of 
which he was cured before the ceremony. She bears one, two, or 
three children successively, always making a satisfactory recovery 
and remaining in robust health. Following a third or fourth preg- 
nancy she develops puerperal septicemia, and is ever afterward a 
sufferer. It can hardly be contended in such a case that gonorrhea 



PELVIC INFLAMMATION, 443 

played a very important role in the production of the septicemia. 
Large numbers of women suffering from pelvic inflammatory dis- 
eases give practically the same history as this, less the fact that the 
husband had had pre-existing venereal infection. 

Generally, when a woman contracts gonorrhea the first step is 
the production of a vaginitis. As it is but a short distance from 
the vagina to the uterus, this is usually quickly traversed. Occa- 
sionally there is no vaginitis noticeable, the first lesion being an 
endometritis. The uterus, in case the infection is of puerperal 
origin, is the original seat of the attack. Whether or not the 
disease starts or exists elsewhere, an endometritis eventually de- 
velops in every case of gonorrheal or puerperal pelvic inflammation. 
This fact is important to bear in mind when it comes to the treat- 
ment of the disease, both as to prophylactic measures and as to the 
final cure, even though surgical treatment has been necessitated 
and carried out. Practically, the mucous membrane of the uterus 
and the Fallopian tubes is one and the same, the anatomical differ- 
ences not amounting to more than a change in the character of the 
epithelium. 

The disease has one unbroken line of membrane over which to 
extend and reach the peritoneal cavity, and it is only a matter of 
surprise that it ever confines itself to the lining membrane of the 
uterus. That it does so in many cases is, however, beyond dispute. 
If the infection be confined to the uterine body, the dangers of 
a peritonitis are very small, as the chances of the poison being 
carried through the uterine walls by way of the lymphatics is not 
great. The extension is nearly always by way of the Fallopian 
tubes, the exceptions to this being found amongst the puerperal 
cases ; and even here an example is rarely met. In such cases we 
would naturally expect the cellular tissue about the uterus to 
become first affected and to undergo suppuration. As a matter of 
fact, such conditions rarely exist, the cellulitis being almost univer- 
sally secondary to the inflammation of the peritoneum. 

One of the many proofs that the infection has proceeded directly 
from the tube itself, and not from the uterus by way of the lym- 
phatics, is that it is rare to find traces of inflammation in the shape 
of adhesions on the anterior surface of the broad ligament, between 
this structure and the bladder. The evidences of the infection are 
almost universally found on its posterior surface, between the lig- 
ament and the sacrum. This would seem to be accounted for by 



444 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the anatomical position of the tube and ovary on the posterior sur- 
face of the broad ligament. 

The more virulent the infection and the more rapidly it extends, 
the greater will be the chance of its reaching the peritoneal cavity 
through the open fimbriated end of the Fallopian tube ; the greater, 
in consequence, will be the destruction to the various organs, and 
the more will be the chance of a fatal termination. 

As the infection extends from the uterus, it spreads at once along 
the mucous membrane of the Fallopian tube, out of its fimbriated 
opening directly on to the ovary and into the pelvic peritoneum. 

Pathological Ain^atomy. — The inflammation engendered by the 
infection, whatever it may be, is in all respects the same whether 
confined to the Fallopian tube, the ovary, a part or the whole of 
the pelvic peritoneum and cellular tissue, or to the whole abdom- 
inal cavity. It is simply a question of anatomical limitation, 
the extent of limitation being determined by the character of the 
infection, its virulence, and the ability of Nature to quickly meet 
and confine it within a limited space. Usually, Nature is capable 
of meeting the invasion more than halfway, and she not infrequently 
shuts off the most important avenue of approach to the pelvic cavity 
by firmly sealing the fimbriated openings of the tube. If she be 
successful in accomplishing this, there is no very great danger that 
the inflammation will pass through the walls of the tube, and thus 
infect the pelvic cavity to more than a limited extent. The possi- 
bility of this must be borne in mind, as undoubtedly the inflam- 
mation has spread in this manner, but only, however, in particularly 
virulent cases. Such instances are the exception rather than the 
rule. 

Whatever be the source or cause of infection, the results are the 
same up to a certain point, as in all inflammations. The moment 
the tissues are involved, there occurs first a congestion, followed 
rapidly by effusion. Resolution may or may not follow later in the 
progress of the case ; the rule is that it takes place to a greater or 
less degree. If resolution does not occur, either organization or 
suppuration is the final step. Whether the inflammation be a super- 
ficial one, involving only the mucous membranes of the Fallopian 
tube or the serous membrane of the pelvic cavity, or whether it 
will extend into the deeper structures of these parts, will depend in 
great measure on the virulence of the attack and its rapidity of 
advance. For the most part, the disease invades, to a greater or 



PELVIC INFLAMMATION. 445 

less extent, the connective tissues : as a matter of actual fact, few 
cases of salpingitis and peritonitis exist without some involvement 
of the deeper and looser tissues. The exudation occurs in two 
places : on the surface of the membrane and into the underlying 
connective tissue. In the Fallopian tube the mucous membrane 
excretes serum which collects and dilates the tube-cavity. This 
fluid is liable to either discharge itself into the uterine cavity 
through the uterine opening of the tube, or into the pelvic cavity 
through the fimbriated opening, or it may be retained and accumu- 
lated in consequence of both these openings becoming closed by the 
inflammatory process. Whether retained or not, it is extremely 
liable to undergo suppurative changes and terminate in pus-form- 
ation. Should this material empty itself into the uterus, it will drain 
into the vagina, and will be eventually disposed of in a comparatively 
harmless way. If it remain encysted in the Fallopian tube, we will 
have formed either a hydrosalpinx or a pyosalpinx ; most usually the 
latter. The amount poured out is variable, depending upon the 
irritating properties of the infection. Should it discharge itself into 
the pelvic cavity, whether it has undergone suppurative changes or 
not, it is liable to set up an inflammatory condition of the pelvic 
peritoneum, even though this membrane be not already involved. 
The exudation into the connective tissue also varies in degree and 
kind. The greater the exudation and infiltration of inflammatory 
cells, the thicker and denser become the tube-walls. So thoroughly, 
in fact, may the walls be penetrated by the inflammation that the 
peritoneum covering them may become involved. The infiltration 
may subsequently become absorbed; it may remain and undergo 
partial organization or it may take on suppurative changes. Fre- 
quently, when to the naked eye a Fallopian tube appears to be per- 
fectly free from suppuration, the microscope will show indubitable 
evidence of the infiltration of pus-corpuscles into its walls. This 
may, and does, frequently extend to the degree of rendering all the 
involved tissues so thoroughly friable as to cause them to break 
down under slight manipulation or under the pressure of a ligature. 
A ligature will at times cut through such tissue like a knife, the 
blood-vessels alone ofiering any great resistance, and even these 
give way in many instances. It is not at all unique to see the sup- 
purative process extend so far that pus may readily be extruded 
from the cut surfaces of the walls of the thickened and diseased 
tube. Should the infiltrating products of the inflammation not be 



446 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

absorbed, they nvdj leave the tube in a permanently thickened and 
hypertrophied condition. There will result in this case an enor- 
mous overgrowth of the connective-tissue elements, with a possible 
permanent infiltration of inflammatory cells. Where the disease 
in the tube has extended to 'either of the above conditions, the peri- 
toneum will have become sufiiciently involved to throw out plastic 
lymph, which will undergo partial organization and form adhesions. 
Should the attack prove a mild one, in all probability the exudation 
will be absorbed and the case progress toward a complete cure. At 
times, where the disease in the uterus is quite severe, it will stop 
short of an inflammation in the tube, and after existing for a time 
as a congestion may gradually disappear altogether. It is no infre- 
quent thing to find at the time of an ope]*ation that the uterus is 
badly diseased, and the tube is only, as yet, greatly swollen and 
deeply congested, but without showing any signs of infiltration. 
So also with the peritoneum. A badly crippled tube may exist, the 
fimbriated end becoming closed and adherent to the ovary, with the 
tube-cavity distended by a muco-purulent serum. The serous mem^ 
brane may be simply congested, with no excretion of lymph, no 
adhesions, no true inflammation. The removal of the tube with its 
contained source of infection and irritation is amply sufiicient to 
put a stop to further advance of the disease : before the patient is 
recovered from the operation all traces of the peritoneal congestion 
will have disappeared. 

Should the inflammation have spread from the tube to the pelvic 
cavity, either by the extension of the disease from the tube through 
its fimbriated opening or by the subsequent pouring out of the 
excreted tubal serum, which has undergone muco-purulent changes 
or not, or by direct extension through the walls of the tube itself, 
the disease takes on exactly the same form as it would in any other 
serous membrane, diflering only in so far as the anatomical features 
differ. The pathology of peritonitis is like that of inflammation of 
other serous membranes — first, congestion, then transudation of blood- 
serum, and, finally, an exudation of plastic material. Should reso- 
lution take place, these inflammatory products are disposed of by 
absorption of the serum and organization of the exudate. Organ- 
ization simply consists in the development of the circulation in the 
exudates sufficient to prevent their degeneration. Should this not 
occur, they usually break down into suppuration. The exudation 



PELVIC INFLAMMATION. 447 

of the serous membranes assumes one of three forms : fibrinous^ 
serous, or suppurative. 

In the fibrinous form, should two opposing surfaces touch one 
another, they will almost certainly become adherent until such time 
at least when the lymph becomes absorbed. If it does not disap- 
pear finally by absorption, permanent adhesions result, more or less 
dense and well organized in accordance with the original amount 
of lymph excreted and the activity of proliferation in the under- 
lying endothelial cells of the serous membrane. The more exten- 
sive the involvement of the peritoneum, the more extensive will be 
the resultant binding together of its various surfaces. Should the 
exudation prove to be of the serous variety, adhesions are much less 
apt to form. Varying quantities of free serum, in a more or less 
changed condition, will be found in the pelvic cavity, and the serous 
surface will most likely be covered with flakes of lymph. The sup- 
purative variety is simply an advanced stage of either of the other 
two. As to whether or not suppuration occurs, depends, again, 
upon the character of the infection. Occasionally the infection is 
so virulent that the case has progressed to a fatal termination before 
suppuration has had time to occur. 

Should the inflammation involve the deeper tissues, as is almost 
always the case, efiusion takes place into the cellular tissue. The 
extent to which this will occur is dependent directly upon the activ- 
ity of the advancing inflammatory process. At times the effusion 
is slight in quantity, and causes but little distension of the loose 
areolar tissues ; in other cases so much effusion is thrown out as to 
distend the connective tissues to their fullest extent. The greater 
the amount of effusion, the more hard and board-like will the part 
appear to the touch on a local examination. Should the case prog- 
ress favorably, there will eventually be an absorption of these 
inflammatory products and the parts will return to a condition of 
health. Should anything supervene, on the other hand, to prevent 
Nature from absorbing and disposing of this serum in the ordinary 
way, it becomes denser and apparently makes an effort at organiza- 
tion. If infective germs should reach it from any direction, suppu- 
ration will take place and all hopes of a spontaneous cure will be 
lost, except through* a prolonged and extremely hazardous illness. 
The extent of the suppuration does not altogether depend upon the 
extent of the infiltration, for the reason that after this process has 
progressed to the limits of the eff*usion it very frequently con- 



448 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

tinues on, involving the healthy connective tissue, step by step, 
until eventually it may involve most of the connective tissue of 
the pelvis, and has even been known to discharge at the umbilicus. 

Except in a limited number of puerperal cases, the course and 
termination of a septic or specific inflammation of the uterus are 
as described. The few exceptions to this rule occur, as has been 
said, in puerperal patients. A woman contracts septicemia after 
childbirth or abortion, by having septic germs introduced into the 
uterus. The amount of septic material which will be necessary to 
contaminate a woman under these circumstances will probably be 
such as would have no eflect whatever upon a healthy non-gravid 
womb. After the placenta has been removed there is left, to all 
intents and purposes, an open wound, or what would be an open 
wound were it on any of the skin surfaces of the body. 

The incidental wounds due to traumatism add another element 
to the dangers of this variety of infection. The placental wound 
is peculiarly liable to pathological changes, for the reason that it is 
difficult of access and treatment, such as a similar wound elsewhere 
would receive. Again, the torn ends of the hypertrophied vessels 
and other tissues are disposed of by a process of degeneration 
which borders closely upon the pathological — a physiological pro- 
cess which the slightest amount of contamination by septic matter 
will change into a pathological one. Should such a wound once 
become septic, the enormously enlarged lymphatics stand ever 
ready with their gaping mouths to receive and convey into the 
deeper tissues the products of the suppuration. One would imagine, 
with the frequency of the occurrence of puerperal septicemia, that 
this condition would result frequently, when, as a matter of fact, it 
is the exceptional occurrence. If the septic products are taken up 
by the lymphatics, the chances are largely that they will be con- 
veyed into the blood without any particular involvement by the 
inflammatory process of the walls of the lymphatic vessels or of the 
connective tissue binding them together or through which they pass. 
At times, however, some additional element seems to be introduced 
which causes th^ inflammatory process to pass rapidly along and 
about the walls of the vessels and lymphatics directly into the sur- 
rounding connective tissue, thus conveying 'the septic material 
primarily into the connective tissue and rendering any peritonitis 
which may follow secondary to the cellulitis. The fact of the exist- 
ence of this class of cases (although of great rarity) does not detract 



PELVIC INFLAMMATION. 



449 



from the statement that in the vast majority of cases of pelvic 
inflammation the cellulitis is secondary to the peritonitis, and is. 
consequently of only comparative importance. Usually the treat- 
ment directed toward the cure of the peritonitis accomplishes also 
that of the cellulitis. 

Results. — The results left in the train of an inflammation 
beginning in the uterus, extending into the Fallopian tubes, and 
from thence into the pelvic cavity, are widely variable. In the 
tube they extend from a slight salpingitis to a pyosalpinx ; in the 
peritoneal cavity, from a mild attack of local peritonitis to a general 



Fig. 298. 




A B 

Normal Fallopian Tube : A, section from the ampulla ; B, section from near the uterus. Layers of the 
Fallopian tube : 1, iipper and outermost layer, serous coat ; 2, layer of loose connective tissue, richly 
oupplied with blood-vessels; 3, muscular coat, much thicker near the uterus than near the ampulla. 
It is principally made up of circular fibres. Above and within it is reinforced by longitudinal fibres, 
some of which spread into the mucous layer ; others (the most external) penetrate between the layers 
of the broad ligament ; still others go to the hilum of the ovary or are prolonged to the fundus of' the 
uterus ; a few fibres penetrate to the inner layer. 4, mucous coat. The framework of this layer is 
embryonic connective tissue, rich in fusiform cells ; it projects into the lumen of the tube in longi- 
tudinal folds which have been cut through obliquely in the section shown above. Near the uterus 
these folds are radiating, and give a star-shaped appearance to the lumen in the section. Near 
the ampulla they are longer and reduplicated, giving the lumen a jagged or toothed appearance on 
section. The whole surface of the mucous membrane is lined with simple columnar ciliated epithe- 
lium ; the movement of the cilia is in the direction of the uterus. 



suppurative peritonitis and cellulitis ; in the ovaries, from a simple 
ovaritis to an ovarian abscess. In the milder forms of salpingitis 
the disease assumes the catarrhal type. Here the inflammation is 
confined almost, if not entirely, to the mucous membrane lining the 
Fallopian tube, there being oftentimes an accompanying congestion 
of the other constituent parts. The cause of the tubal involvement 
is always resident in the uterus, usually in the shape of an endo- 
metritis, and occurs by direct extension from one mucous membrane 

29 



450 



AN AMERICAN TEXT- BO OK OF GYNECOLOGY. 



to the other, the disease in the tube not always being so severe as 
that in the endometrium. The process exists in both an acute and 
a chronic form. Neitlier gives rise to any particular symptoms 
other than indirect ones, such as sterility. The acute form may 
run its course rapidly and be spontaneously cured, or may subside 
as the endometritis is relieved. On the other hand, it may continue 
on indefinitely, and finally become chronic. During the existence 
of the inflammation, especially in the acute form, an excess of sero- 
mucous products is thrown out. Where there are no adhesions 
found, but the uterine and fimbriated ends of the tube remain patu- 

FiG. 299. 




Hydrosalpinx. 



lous, these products are drained either into the uterine or pelvic 
cavities. Should their openings become occluded from any cause, 
as is at times the case, the sero-mucus accumulates, distends the 
tube, renders its walls thin, the tube becoming larger and larger as 



PELVIC INFLAMMATION. 



451 



the contents increase. The condition is then known as hydro- 
salpinx. The very mild cases seldom terminate in this manner, for 
the reason that there is not sufficient active inflammation to cause 
occlusion of the tubal openings. Where a hydrosalpinx exists, it 
is often found to be adherent to surrounding parts. The fact of the 
presence of a healthy, non-inflammatory tumor of reasonable size 
being present in the pelvis is not in itself sufficient to account for 




Hydrosalpinx. 



inflammatory processes arising in its peritoneal lining. Either the 
original inflammation, slight as it may be, has spread through the 
walls of the tumor, which have become much thinned, or there has 
been leakage of some of the tube-contents, which are acrid and 
irritating. 

Should the inflammation become a chronic condition, which is 
the more usual procedure, the result is more apt to be a destruc- 
tion of the ciliated epithelium lining the tube, and a consequent 
permanent crippling of that organ for its legitimate functions. 
The desquamation of the epithelium is also claimed to be a sequel 
of the exanthematous disease. To how great an extent this is true 
is uncertain. There is not the slightest reason why this mucous 
membrane should be more affected than that of other parts of the 
body. Where there has been a general and undoubted involvement 
of all the mucous tissues in the body there is no reason to expect 
that this particular one has escaped. Otherwise, the cause and 



452 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

effect of these diseases are extremely problematic. It is this de- 
squamation of the ciliated epithelium in the catarrhal salpingitis 
which is in great measure responsible for a large proportion of cases 
of sterility and extra-uterine pregnancy. The normal function of 
the ciliated epithelium is to carry all the tube-contents toward the 
uterus. If in consequence of its destruction the ovum is retarded 
in its progress until the spermatozoid is too enfeebled to perform its 
function, or if the ovum simply lodges in the tube and there loses 
its vitality, sterility must of necessity follow. Again, if the dis- 
charges from the altered and diseased mucous membrane are acrid 
and acid, neither the ovum nor the spermatozoid can survive, or at 
least they are so enfeebled when they meet that they fail to unite, 
or if they unite, fail to accomplish their destiny. Should the calibre 
of the tube be closed at any point throughout its extent, of course 
an insurmountable mechanical obstruction exists which it is impos- 
sible for either element to overcome. If the male and female ele- 
ments should meet in the tube and the ovum become fecundated, the 
product of conception is very apt to lodge at some point along the 
course of the tube and continue its development. 

Occasionally the inflammation of the tubal membrane assumes 
the hemorrhagic type and the excretions are mingled with blood. 
Provided these muco-bloody discharges empty themselves into the 
uterus, there will be no more difference in the result than if the 
excretion were merely mucous or serous. If adhesions close the 
ends of the tube, it becomes distended with the contained fluid, as 
in hydrosalpinx, and is then known as hematosalpinx. This 
occurrence is infrequent as compared with the formation of hydro- 
salpinx. 

When the infection is more severe and extends into the Fallopian 
tube from the endometrium, involving almost simultaneously all the 
layers of the tubal wall, the resultant condition is more important 
as well as more dangerous. Exudation takes place into all the coats 
of the tube, and the inflammation extends even to the peritoneum. 
The openings into the tube may become closed or may remain pat- 
ulous ; usually they are occluded. The inflammatory products in 
the walls of the tubes increase. The walls vary in thickness in 
accordance with the amount of infiltration, in particularly bad cases 
being from a quarter to half an inch thick. Attempted organiza- 
tion may take place, the result being the production of an over- 
growth of the connective- tissue elements, giving the tube a greater 



PELVIC INFLAMMATION. 453 

or less consistency. The products of inflammation thrown out by 
the mucous surfaces are either discharged through the tubal open- 
ings or, if the openings are not patulous, are absorbed. The inflam- 
matory products thrown out on the peritoneal covering of the tube 
assume the form of plastic lymph, and cause the tube to adhere to 
any other peritoneal surface it may touch. The tube itself adheres 
commonly to the uterus, broad ligament, and ovary : the fimbriated 
end usually grasps the ovary tightly, and the fimbria themselves 
may become destroyed by the disease. 

This condition presents the disease known as chronic (adherent) 
salpingitis. It must be borne in mind that this condition is dis- 
tinctly different from those forms of pure chronic catarrhal salpin- 

FiG. 301. 




Chronic Interstitial Salpingitis and Ovaritis, with thickened broad ligament— so-called cellulitis. 

gitis in which the inflammation affects only the mucous lining of 
the tube, and results simply in a permanent alteration of that mem- 
brane, without particularly affecting the walls of the tube or its 
investing peritoneal covering. 

Chronic interstitial salpingitis is nothing more or less than the 
mildest form of the same condition, which frequently progresses to 
the development of a pyosalpinx. If there be good drainage of 
the tube, there is not much danger of muco-purulent material 
accumulating. There may, it is true, be a certain amount of 
suppuration taking place, even the walls of the tube becoming 
involved. The result under these circumstances would be in accord- 



454 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



ance with the patency of the tubal canal. If the canal remains 
patulous^ the only additional harm will be the breaking down of 
the inflammatory products infiltrating the walls, and the consequent 
rendering of these friable, if they do not actually suppurate. This 

Fig. 302. 




Fallopian Tube and Ovary, showing adhesions. 

same process may extend on into the lymph thrown out by the 
peritoneum, and cause the adhesions to become friable or even to 
suppurate. 

Should suppuration occur, inflammatory products within the 
tube may drain away into the uterus, and the suppurative process 
finally cease, leaving the tube in its crippled adherent condition. 
The uterine opening will remain patulous long after the fimbriated 
opening is closed and the fimbria destroyed, for the reason that the 
peritoneum is much more delicate than the endometrium, and the 
irritation of the advancing suppuration will cause it to early throw 
out protective lymph, which will effectually seal the opening and 
protect the peritoneal cavity. The suppurative process may keep 
up indefinitely, the tube constantly discharging its muco-purulent 
contents into the uterine cavity and thence into the vagina. This 
is of no infrequent occurrence. The uterine opening may even 
become closed by light friable adhesions, the tube distend with its 
suppurative contents, until either the pressure of the over-disten- 
sion causes the adhesions to give way or they break down from 
suppurative changes, the result in either case being a periodical 
discharge of pus from the tubes. The tubal openings usually 
become permanently closed by adhesions. If the tubal contents 
are small in quantity, they may eventually become absorbed ; but 
this cannot be a common termination. It is not of infrequent 
occurrence to find the Fallopian tube distended with a broken- 
down, cheesy material. In these cases the watery elements of 



PELVIC INFLAMMATION, 



455 



the pus have been absorbed, and the solid portions have under- 
gone a caseous degeneration. Such conditions are very apt to be 
due to tubercular changes. Were the constituent tissues of the 
tube healthy, there would be more probability of complete absorp- 
tion. In the cases under consideration all the parts of the tube are 
so diseased and disorganized that their functions are for the most 
part suspended. However, certain cases are met with clinically in 
which no other interpretation is possible, and it may be put down 
as one of the probabilities. 

When the contents are not absorbed, a true pyosalpinx results. 
The tube becomes distended with a greater or less quantity of pus 



Fig. 303. 




Double Pyosalpinx and Diseased Uterus, removed by Supravaginal Hysterectomy, 

or muco-purulent matter. In such cases the inflammatory infil- 
trates in the tube-walls have most probably shared in the suppu- 
rative changes, rendering the walls soft and cheesy ; the microscope 
will show them filled with pus-corpuscles. The peritoneal serum 
and lymph do not escape the suppurative changes. The pus may 
have worked its way directly through the tube-wall, and then 
infected the lymph, or the infection may have passed through the 
fimbriated opening of the tube, and in this manner contaminated 
the peritoneal elements. Small abscesses frequently result, in con- 



456 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



sequence, in the midst of the adhesions, and on removal of the tube 
by abdominal section these abscesses, which are as often as not 
multiple, are opened, their contents soiling the field of operation. 
If the pus has passed directly through the tube-wall, these small 



Fig. 304. 




Pyosalpinx and Ovarian Abscess. 



local abscesses will probably be the worst result. Should the infec- 
tion pass out through the fimbriated opening, however, it may 
spread rapidly to the whole pelvic or abdominal cavity, and end in 
a general suppurative peritonitis. The reason of this difference is 
that when the suppuration extends through the tube-walls it never 
enters the general peritoneal cavity, but always meets the obstructing 
lymph which the peritoneum has had plenty of opportunity to 
throw out about the threatened point. This same obstruction is 
most always met with at the fimbriated opening, in which case the 
result is the same ; but occasionally the infection itself travels 
along the tubal mucous membrane so quickly that it has time to 
escape before it can be closed in by the peritoneal lymph. 

When the infection has once passed beyond the fimbriated open- 
ing of the Fallopian tube, it attacks either the ovary, the pelvic 
peritoneum, or both. Should it confine itself to the peritoneal 
investment of the ovary, it causes excretion of lymph, which binds 
that organ to the tube. The fimbriated end of the tube becomes 



PELVIC INFLAMMATION. 457 

firmly attached to the ovary, not infrequently an abscess developing 
at the point of junction, which is known as a tubo-ovarian abscess. 
Should the infection penetrate the outer coat of the ovary or infect 
a ruptured Graafian follicle, an abscess will begin and form in the 
ovarian stroma which may eventually reach even the size of an 
orange. Such an ovary is, as a matter of necessity, on account of 
the involvement of its peritoneal covering, densely adherent to all 
peritoneal surfaces which come in contact with it. Where there is 
no infection, but where the inflammation spreads from the tube and 
involves the ovary, this organ takes on changes of an interstitial 
character, which eventually cause such a destruction that there is 
left little of the healthy ovarian stroma. At times these organs 
assume much the character and appearance of hypertrophic scirrhosis ; 
at others, an atrophic condition. In either case the function of the 
organ is much changed, even destroyed, and the ovary is most 
likely to give rise to very distressing symptoms. 

The infection may pass along the Fallopian tube and infect the 
ovary, even to the extent of forming an ovarian abscess, without 
leaving behind more than a catarrhal condition in the tube. When 
the infection invades the peritoneum, it remains often a local affec- 
tion, but in a reasonably large proportion of cases spreads until 
it invades more or less the whole of the pelvic peritoneum. It 
may, in fact, continue and develop into a general abdominal 
peritonitis. In attacking the peritoneum any one of these forms 
of peritonitis are likely to develop : the fibrinous, the serous, or the 
suppurative. The fibrinous variety is by far the most frequent 
form accompanying inflammatory diseases of the Fallopian tubes 
and the ovaries. The serous variety is most likely to be of the 
nature of that peritonitis which so often follows the performance 
of a coeliotomy ; it runs its course usually in three or four days, and 
most generally ends fatally. It may, as a matter of fact, occur 
under anv source of infection. The lesions in such a case, on 
examination, will be found to be universal but light adhesions 
between all the coils of intestines located in the pelvic cavity, as 
well as of all the pelvic contents. After the various organs are 
separated a few ounces of bloody serum will be found in the pelvic 
basin, and the peritoneal surfaces will be observed to be covered 
with flakes of lymph. The process has been too rapid for the 
formation of pus in many instances, and as a rule there is not 
a great deal of involvement of underlying connective tissue. The 



458 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

fibrinous variety is the common one. The irritated and inflamed 
serous membrane begins at once to develop that great protector, 
lymph. This material precedes the infection, and, unless the 
advancing inflammation is too rapid, bounds it within certain limits. 
Frequently it confines the inflammation to the serous covering of 
the tube itself. The inflammation may have advanced further and 
involved the serous covering of the ovary and the broad ligament. 

As the inflammation advances step by step it is continually met 
by the obstructing plastic material which the threatened and irri- 
tated peritoneum is throwing out for its protection, until, having 
spent its forces, it makes less and less effort at advance, and finally 
settles down within the limits into which the lymph has been able 
to confine it. 

The extent of the destruction will have depended much upon 
the rapidity of the advance and the virulence of the infection. 
The lymph may have succeeded in confining it to the immediate 
neighborhood of the diseased Fallopian tube -and ovary, or the 
inflammation may have spread to the whole of the pelvis, or in 
extreme cases to the general abdominal cavity. The inflamed 
peritoneal surfaces, wherever they come in contact, become glued 
together by the lymph. By the time the inflammatory forces 
have spent themselves, the serous membrane is infiltrated with the 
inflammatory products, resulting in its becoming thickened as well 
as being covered with lymph. 

Should the case terminate in the most favorable manner, all the 
lymph and other inflammatory products would become partially ab- 
sorbed, and the other parts return once more to a comparative con- 
dition of health. It is at this point that electricity has gained its 
greatest reputation. The lymph exists in considerable masses, and, 
as Nature begins to get rid of this accumulation, electricity comes in 
as an extra spur to hurry Nature's work. The result is in many 
cases a quicker absorption and an apparent cure, the facts being 
that the gross amount of lymph has disappeared, but the disor- 
ganized and adherent appendage remains, ready to relight the 
original inflammation upon the slightest provocation. 

The fact is notorious that these chronic conditions are liable to 
repeated recurrent acute exacerbations of inflammation. 

The more usual result, however, of such an inflammation of the 
pelvic peritoneum spreading from the Fallopian tube is to cause a 
broken-down and destroyed tube and ovary ; both become enlarged, 



PLATE XXX. 




j-^f^ 



Pyosalpinx and Ovarian Abscess, showing the remnants of universal adhesions. 



PELVIC INFLAMMATION. 



459 



heavy, prolapsed, and adherent to each other, the broad ligament, 
the uterus, and the pelvic walls. One step further, and the superim- 
posed intestines and omentum are involved, and become adherent 
on top of the diseased and adherent pelvic organs. At times there 
is no pus complicating the general destruction ; at others pus is 
found in the Fallopian tubes, the ovaries, in the midst of the adhe- 
sions in which these organs are imbedded, or filling the whole pel- 
vis. The Fallopian tubes themselves are so distorted that numerous 
separate pockets of pus are found in a single tube. As many as 
three such collections have been found in the same tube, each of 

Fig. 305. 




Broad thin Band of Adhesions (spider-web) hanging from an Adherent Ovary and Fallopian Tube. 

(Drawn from photograph.) 



which contained a distinctly different variety of pus. As many as 
half a dozen different foci of suppuration have been found in the 
midst of the adhesions, and in a single Fallopian tube, all separate 
and unconnected with each other. 

Should the infection not be virulent enough to cause suppura- 



460 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



tion of the serum and lymph, this latter substance will undergo 
organization to a greater or less extent, with the result of leaving 
the surfaces which have come in contact permanently adherent. 
The adhesions thus found are variable in kind ; clinically at least 
four varieties are recognized. 

The Fallopian tubes, ovaries, and uterus, one or all, may be cov- 
ered over with a thin layer of false membrane, well organized and 
not at all unlike a spider-web, when spread out and held up to the 
light. The variety has well been called the " spider-web adhesion.^' 
The membrane is easily torn to pieces and destroyed if the finger is 
pressed through it while it is on the stretch. If, in attempting to 
break through, it is allowed to gather itself together like a bundle 
of sticks, it forms long shreds of adhesions which are exceedingly 
hard to tear, and in the tearing of which an intestine or bladder 
may easily be badly injured, its walls giving way at the point of 
the adhesions. They are the more difiicult to deal with inasmuch 
as the organs are usually movable under them7 and it is hard to get 
any fixed point from which to break through. 

The next variety is that where any or all of the pelvic organs 
become fixed in the lymph in much the same manner as if they 

Fig. 306. 




Ovary Displaced and bound Down in the Cvl-de-sac by Adhesions— adhesions of the spider-web variety; 
similar to those shown in Fig. 305 : ro, right ovary ; lo, left ovary. 



were set down in a bed of plaster of Paris. The lymph organizes 
and from it is formed a new and apparently real peritoneal cover- 
ing. Clinically, to the touch, the organ feels as though it had been 
congenitally developed in its displaced and distorted position. In 



PELVIC INFLAMMATION. 461 

the case of the ovary the ovarian ligament is destroyed ; where the 
Fallopian tube is involved the broad ligament has, to a greater or 
less extent, disappeared. The organs are immovably fixed, and 
can only be torn away from their position by an absolute enuclea- 
tion, there being practically no pedicles to deal with : to all intents, 
the mass removed is a sessile growth, and must be dealt with as 
such. The cases in which this condition is found are usually old 
chronic ones. 

The ordinary adhesion met with in the course of operations is 
what one might call the " bread-and-butter" variety. After the ad- 
herent surfaces have been freed from each other the appearance is 
not unlike the surface of two pieces of bread and butter which have 
been placed together as in a sandwich and separated. These adhe- 
sions are more or less firm as the case is an acute or chronic one. 
At times they are so solid that it is necessary to take the handle of 
the scalpel or other instrument in order that they may be safely sep- 
arated ; in other cases the finger will readily destroy them. Should 
the lymph going to form these adhesions become infected, they 
become more or less broken down, and are proportionately easy to 
deal with. This forms the fourth variety as seen clinically. Nat- 
urally, the only pathological difference between at least the last 
three varieties is the difference in the extent of involvement and 
organization. They all begin by the affected organs becoming 
imbedded in a quantity of plastic lymph. This lymph organizes or 
is partially broken down by the infectious poison. If it breaks down 
and fails to organize, the last clinical variety is produced. This 
variety usually accompanies acute pus-tubes. Should it fail to do 
more than make an attempt at organization, the adhesions will go 
to make up that variety which is the most common, the " bread- 
and-butter " variety, which generally accompanies chronic (adhe- 
rent) salpingitis. It is almost always possible in enucleating the 
organs in such a case to find the broad and ovarian ligaments and 
use them as a pedicle, although at times they are much shortened. 
If the case runs on into a chronic form, either of the last two 
varieties may develop, by absorption of the degenerative elements 
and by organization and contraction, into those varieties which re- 
s'emble so much congenital conditions. 

Finally, the lymph may break down into suppurating foci at 
one or more points, local abscesses being the result. These abscesses, 
being bounded by adherent lymph, are for all practical purposes 



462 AN AMEBIC AN TEXT-BOOK OF GYNECOLOGY. 

extraperitoneal, and yet they are as truly, from an anatomical point 
of view, intraperitoneal as if they were not limited at all. As a 
matter of fact, they exist from cavities as large as a pea to abscesses 
filling the whole of the pelvis, and only being shut out from the 
general abdominal cavity by the intestines and omentum at the pel- 
vic brim, becoming involved in the advancing inflammation, lymph 
being thrown out, and these organs becoming firmly adherent over 
and about the pelvic inlet. 

Unless the attack has been a mild one, the connective tissue 
immediately underlying the peritoneum is apt to become involved 
in the destruction. So intimately connected are the two structures 
that where the one is affected by such a serious process it can readily 
be understood why the other also becomes involved. As soon as 
this loose areolar tissue is invaded, the products of inflammation are 
thrown out into its meshes, and the parts affected become much 
thickened. The connective tissue of the broad ligament and that 
underlying the peritoneum which lines the pelvic floor are most apt 
to be affected. The infiltration, as usual up to a certain point, 
attempts to undergo organization, but mostly fails. It is either 
absorbed or suppurates. 

Should it become absorbed, it would do so in conjunction with 
the absorption of the inflammatory products in the peritoneum and 
in the line of progress toward the cure of the whole pelvic inflam- 
mation. If organization partially occurs, a contraction of all the 
tissues takes place, with the result in some cases of almost total 
obliteration of the ligaments and contained connective tissue. This 
is the condition which has existed in those cases of prolapsed and 
adherent tubes and ovaries, where the ligaments have almost, if not 
entirely, disappeared and the organs remain practically as sessile 
masses. Cellulitis is essentially an acute or subacute as well as a 
secondary disease. It rarely occurs in the pelvis as a primary dis- 
ease, and is just as rarely found as a chronic condition, except 
in the form of an abscess, which is not common. The abscesses 
and masses in the pelvis formerly looked upon as cellulitis are 
almost without exception contained within the peritoneal cavity ; 
where the abscess does exist in the cellular tissue, it is generally an 
extension from a focus of suppuration in the peritoneum. It is 
said that in acute puerperal cases the infection, at times, extends by 
way of the lymphatics directly into the cellular tissue, and results 
in the formation of a true cellulitis and a true primary cellular- 



PELVIC INFLAMMATION, 463 

tissue abscess. Examples of such cases have from time to time 
been placed on record by reliable authorities, but they must be of 
exceedingly rare occurrence, as the writer during the course of 
many hundreds of coeliotomies has failed to find a single exam- 
ple of the condition. In no case, except in suppurating cysts, 
has a pelvic abscess been observed which was not intraperitoneal, 
in the sense that it had originally developed in the peritoneal 
cavity. 

These pelvic abscesses, whether of peritoneal or cellulitic origin, 
are extremely apt to burrow their way to the surface and discharge 
their contents in a more or less irregular manner. They have been 
known to empty themselves into the rectum, vagina, and bladder. 
The umbilicus, the saphenous opening, the pelvic floor, the labia, 
the pelvic foramina, have all served as means of passage for the 
pus. Cases have even been reported where the pus has burrowed 
through the connective tissue to the iliac fossa, and from thence to 
the diaphragm, finally rupturing into the lung. The spontaneous 
evacuation of pus by any of these sources, although a proportion 
of such cases go on to a good recovery, is a disaster, and the danger 
of such a result is one of the clearest of indications for the adoption 
of vigorous measures to ensure its prevention. The usual course 
of a case after such a mishap is a prolonged convalescence — -just as 
commonly a long invalidism, followed by death. The sinus-tracks 
are long and irregular, and the abscess-cavities very incompletely 
drained. In the case of the rectum and the bladder the cavity is 
continually contaminated by the contents of these organs, and an 
already bad condition is rendered worse. 

Symptoms. — These vary in accordance with the anatomical parts 
attacked and the intensity of the inflammation. 

The amount of suffering incurred by the patient will vary from 
a matter of slight discomfort to agony which is quite beyond 
description. There is no death from which a woman may die 
which is, in all its features, more distressing than a death from 
peritonitis, especially an acute septic peritonitis. The symptoms 
of each of the parts attacked are in many respects similar. The 
involvement of almost all the tissues of the pelvis follows as a 
complication wherever the brunt of the attack may fall. In other 
words, one tissue is seldom involved without all being more or less 
included ; consequently the symptoms which would be induced by 
the attack of one tissue are present at the same time with those 



464 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

which would be induced by the involvement of any or all the other 
tissues. 

There are three symptoms which are present in greater or less 
degree in almost all, if not quite all, cases of pelvic inflammations. 
Pain, hemorrhage, and uterine discharges usually dominate all 
other factors in cases in which suppuration has not supervened. 
Naturally, the temperature and pulse play a conspicuous part. 
When suppuration occurs, all the symptoms of septicemia are 
added to those already existing. In addition, symptoms referable 
to special organs and due most frequently to sympathy and reflex 
influences become at times prominent. 

Salpingitis. — In acute or chronic catarrhal salpingitis the symp- 
toms are seldom sufiiciently prominent to give rise to any suspicion 
that there is such a disease present. In the acute form the patient 
will most probably feel a condition of general malaise, have some 
backache, with a possible headache ; there may be a slight increase 
of the discharge coming from the vagina. No noticeable change 
takes place in the menstrual function, for the reason that this is 
already, in all probability, disordered from a pre-existing endo- 
metritis, and the lesion in the tube is too slight to add anything 
perceptible to the result. If at this time the temperature and 
pulse should be taken, the one would be slightly elevated, the 
other accelerated. No doubt in every acute case these symptoms 
are present to a greater or less degree, but in almost every instance 
the attack is so slight that it is passed over without notice, and the 
disease has soon settled itself down into a subacute or chronic form: 
in this condition the symptomatology is even slighter than in the 
acute form. The disease is so constantly associated with endo- 
metritis, being, as a matter of fact, almost always an extension of 
the uterine inflammation, that the symptoms of the primary dis- 
ease are a great factor in obscuring those of the salpingitis. The 
fact that the disease has existed at all is usually only discovered 
when its results are made manifest. It is from this form of the 
pelvic inflammation that hydrosalpinx arises. 

Hydrosalpinx. — The distension of the Fallopian tube with serum 
frequently exists without giving rise to any symptoms whatever. 
If the resulting tumor *is not very large — and usually it does not 
reach a size greater than that of a Messina orange, although occa- 
sional cases are reported of enormous size — there is no particular 
reason that it should cause any disturbance. When it does so, it 



PELVIC INFLAMMATION. 465 

will most generally be found that an inflammation, slight or other- 
wise, has invaded the peritoneum, and that w^hatever symptoms are 
present will be due in great part to the local peritonitis. Adhe- 
sions may result or not, this being determined by the character of 
the peritonitis. Should inflammation of the serous membrane 
complicate the case, it will give rise to pain, either slight or 
quite severe according to the grade of inflammation and the extent 
of the adhesions. Leucorrheal discharges are apt to enter as a 
factor into the case: the discharge is of a whitish character, and 
seldom if ever assumes a muco-purulent form. Should the dis- 
charge be muco-purulent, it is evident that it originates from the 
endometrial inflammation, and is not merely due to the congestion 
caused by slight local peritonitis. Menstrual disturbance is apt to 
be present, as is the case with most examples of pelvic inflamma- 
tion ; the flow is apt to occur too frequently and to be profuse. 

Hematosalpinx — Should the exudate from the mucous membrane 
of the Fallopian tubes take on a bloody character and the openings 
of the tube become occluded, the result is an hematosalpinx. The 
symptoms of this disease differ in no way from those of the hydro- 
salpinx, or those of the adherent salpingitis which will be described 
later. As in the latter disease, the greatest amount of its symp- 
tomatology is derived from the peritoneal involvement, and as the 
extension of the inflammation to the serous membrane is of about 
equal occurrence in both, the symptoms are usually the same. 

Interstitial Salpingitis and Ovaritis. — The name is given this 
form of pelvic inflammation for want of a better one by which to 
designate it. It is meant to include all forms of inflammation of 
the Fallopian tubes and ovaries, excepting those mild ones described 
under the name of catarrhal salpingitis and those described under 
tubercular salpingitis. Leucorrheal discharge will be the first in- 
dication of the trouble, and this will be quickly followed by pain. 
The vaginitis and endometritis which precede the salpingitis will 
have been ushered in with muco-purulent discharge. These dis- 
charges continue when the Fallopian tube becomes involved, and 
the only diflerence then to be noted is that there is added to them 
the discharges from the tubes. This addition is not sufficient under 
ordinary circumstances to be perceptible. Should the tubal dis- 
charges accumulate and distend the tube, it not infrequently 
occurs that the obstruction at the uterine end finally gives way, 
and there is consequently a gush of muco-purulent matter from 

30 



466 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the uterus and vagina. One must be on his guard, however, 
against this symptom as indicative of an over-distension of the tube 
and its spontaneous discharge into the uterus. This is presumed to 
be one of the methods Nature has of curing pyosalpinx, and one 
which, if we are to believe all the reports in the literature of this 
subject, is extremely common. There is no doubt but that such a 
happy termination does occur in some few cases, but their frequency 
-is questionable. The symptom oftentimes only exists in the mind 
of the attendant and the patient, and is due for the most part to 
faulty observation. Some slight temporary obstruction arises in the 
cervical canal, and the discharges accumulate in the uterus, only to 
be expelled as the patient assumes a favorable position ; or, what is 
more common, there is an accumulation in the posterior cul-de-sac 
of the vagina, with a subsequent discharge on certain movements of 
the woman favorable to their expulsion. The symptom is most apt 
to occur in women who are confined to bed, the recumbent position 
favoring such a condition. Leucorrheal discharges are common to 
all inflammatory or congestive conditions of any or all of the pel- 
vic organs. They are therefore not at all diagnostic, and are only 
of value as corroborative evidence. Their character varies as they 
are mixed or not with infection. The purely congestive discharges 
— such, for example, as precede menstruation and accompany preg- 
nancy — are of a milky-white character : those which accompany 
gonorrheal infection or puerperal septicemia assume a muco-puru- 
lent character. It is this latter kind of discharge which almost 
always accompanies adherent salpingitis. As a matter of fact, it is 
a combination of the excretions of the tubes, uterus, and vagina, 
and is made up of the suppurating inflammatory effusions, mucous 
and epithelial cells. The discharge is frequently acrid, and causes 
a pruritus of the vulva. Pruritus is not as common a symptom 
in these inflammatory diseases as we would be led to imagine from 
the amount of the discharges, their acridity, and the constancy with 
which they exist. So infrequently does it occur, in fact, that a grave 
doubt arises as to whether the pruritus is ever due to the discharge. 
Leucorrhea is as apt to appear in the same amount where the inflam- 
mation has attacked the tube alone as where the w^hole pelvic peri- 
toneum is involved. 

Pain is a constant companion of the pelvic inflammatory dis- 
eases. It varies in intensity with the tissues involved and the extent 
of the process. In cases of adherent salpingitis and ovaritis it is 



PELVIC INFLAMMATION. 467 

usually located in one or both iliac regions, at times extending 
down the thighs, and is frequently accompanied by backache. It 
is severe or not as the attack is an acute or chronic one. . Its cha- 
racter is variable, from a dull, heavy backache to a sharp, lancinat- 
ing iliac pain, which does not come and go, but remains, for the 
most part, constant. Often it is due more to the irritation of the 
advancing inflammation than to any real involvement of the tubal 
or ovarian tissues. It is no infrequent thing in gonorrheal or puer- 
peral endometritis to find that the iliac pain disappears after a 
thorough curettement of the uterus, proving that the inflammation 
has not yet passed beyond the uterine cavity. The sharp pains are 
mostly due to peritoneal involvement, and are a fairly sure indica- 
tion that this membrane has been invaded by the actual inflamma- 
tion, or at least is irritated by its near approach. The ovarian 
involvement is, however, responsible for a fair share of the condi- 
tion. The dull, heavy pains, as the backache, are most probably 
produced by the infiltration of all the tissues with inflammatory 
products ; possibly some of the elements of the peritoneal pain are 
added as a factor. Motion or pressure of any kind will aggravate 
this symptom. An over-distended bowel or bladder gives more or 
less distress, and the contraction incident to the emptying of either 
of them causes considerable suflering. Walking, riding, or jarring 
from any cause calls forth this complaint : even the erect position 
may be uncomfortable or unbearable. 

Menstrual disturbances are universal. As a rule, menstruation 
appears too frequently, every two or every three weeks, and lasts 
from the usual time to eight or ten days : occasional cases last for 
as long as two weeks. It is important in weighing this symptom 
to inquire carefully into the past menstrual history. Not uncom- 
monly, women present themseves for treatment in whom a frequent 
and prolonged menstruation is natural, and this condition must not 
be confounded with a pathological one. Where the flow has form- 
erly been fluid, under the altered condition it is apt to become 
clotted and dark. The function is accompanied by pain, which 
may appear some days before the flow and last several days after 
it has ceased. Like all the other symptoms, this one is variable, 
and in not a few cases the flow is scant rather than profuse. Scanty 
menstruation is the exception in inflammatory diseases of the Fal- 
lopian tubes, but that it does exist is undoubted. Suppuration of 
the exudates and an accumulation of pus in the tubes has no very 



468 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

perceptible influence upon these symptoms. Pain, hemorrhage, and 
leucorrheal discharges seem to depend largely upon the amount 
and character of the involvement of the serous membrane; cer- 
tainly pain is almost absolutely dominated by this factor ; possibly 
the altered mucous membranes have the most influence upon the 
other two symptoms. The three symptoms grouped together in 
conjunction, with a history of gonorrhccd infection or of post-puer- 
peral septicemia, are highl}^ suggestive, and yet not much reliance 
can be placed on a diagnosis based upon this data. The three 
symptoms, alone or grouped together, accompany almost every 
disease to which the pelvic organs of the female are heir. These 
symptoms, however, taken in conjunction with certain local condi- 
tions, establish the dia2:nosis almost certainlv. 

As in all inflammations, the temperature and pulse are affected. 
Usually neither of them rises to any very great extent. During the 
first few days of the acute attack they may both be elevated consid- 
erably above 100°. As seen in the subacute or chronic condition, 
it is rather uncommon to note any great deviation from the normal 
where suppuration has not occurred or where the peritoneum is 
only slightly or not at all involved. If the attack has been ushered 
in with a chill or rigor, it is almost certain that either one of these 
two conditions exists. As a matter of fact, peritonitis and cellulitis 
almost always accompany and complicate the salpingitis, and conse- 
quently the symptoms of the two conditions always commingle. 

The tendency of inflammation near or about the bowel is to in- 
hibit peristaltic action, and constipation is the rule. As constipation is 
almost the natural condition of women, however, it adds little to our 
diagnostic resources. On the other hand, the bladder becomes irri- 
table under the same condition, and the presence of the urine causes 
a frequent desire of the bladder to empty itself. Frequent mictu- 
rition and constipation are common symptoms. Any irritation in 
the pelvis seems to give rise to gastric disturbances, and the inflam- 
matory diseases are no exception. Symptoms of dyspepsia, espe- 
pecially flatulence, are ver}^ common, and, in fact, at times give rise 
to more distress than the symptoms referable more directly to the 
pelvic lesions. Distension of the intestines with gas occasions con- 
siderable pain at times — a pain which comes and goes, and which is 
distinctly different from the inflammatory pains. 

Pyosalpinx and Ovarian Abscess. — Should the inflammation prog- 
ress to suppuration, many of the symptoms are apt to become exag- 



PELVIC INFLAMMATION, 469 

gerated, and in addition there is added the condition of sepsis. 
The woman begins to suffer from cold creeps, chills, or even a rigor ; 
the temperature becomes elevated, ranging from 100° to 104°, or 
even higher ; the pulse rises rapidly, and varies from 100 to 140 or 
more beats to the minute. The abdomen becomes swollen, due to 
distension by gas, the walls hard, unyielding, and exceedingly ten- 
der to the touch. The skin surface may become cold and clammy, 
the appetite destroyed, the sleep restless and unrefreshing. A gene- 
ral feeling and appearance of dulness, or even stupor, may super- 
vene. The pain is more persistent and intensified, and is apt to 
assume a more or less deep, throbbing character. As time passes the 
woman's general condition gradually grows more and more serious. 
She loses many pounds of flesh and becomes greatly emaciated ; her 
face has a distressed and shrunken appearance ; her nervous sys- 
tem becomes shattered ; she may or may not be confined to her bed. 
It might easily be concluded from these remarks that no great reli- 
ance could be placed upon symptomatology in the diagnosis of 
inflammatory tubal disease. Such is, in truth, the fact. It is abso- 
lutely necessary that the physical signs be determined by vaginal 
examination before the truth can be ascertained. 

Peritonitis. — The symptoms attributable to this disease are a 
combination of those produced by the inflammation of all the other 
parts of the pelvis. As a matter of fact, the main symptoms attrib- 
utable to pelvic inflammatory cases are produced by the inflamma- 
tion of the serous membrane. Many of the symptoms described 
under different forms of salpingitis originate in or are increased by 
the peritonitis. Inasmuch as peritonitis to a greater or less extent 
complicates the inflammations of the Fallopian tube, the symptoms 
are practically the same, their severity depending much upon the 
extent of the lesion. If only the peritoneum covering the Fallo- 
pian tube be involved, then the symptoms will be similar to 
those already described. When the whole pelvic peritoneum is 
invaded, the pain is more acute ; the temperature and pulse are 
more markedly elevated; the patient lies more comfortably with 
the knees drawn up, for the reason that it relaxes the abdominal 
muscle and takes awav a considerable amount of the intra-abdomi- 
nal pressure ; the expression of the face is apt to be distressed ; the 
abdominal muscles rigid and fixed ; the whole abdomen tender to 
the touch ; the intestines distended with gases, rendering the belly 
tympanitic; the appetite abolished and sleep impossible. Consti- 



470 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

patioii is absolute and there are eructations from the stomach. Such 
is a fairly typical description of a severe attack of pelvic peritonitis. 
There are, in addition, all the symptoms present which have been 
enumerated as accompanying inflammation of the Fallopian tube, 
together with those present when the cellular tissue is involved ; 
which is generally the case. Should suppuration of the exudates 
occur, there will be added the symptoms of septicemia. The differ- 
ence of these symptoms from those arising in a suppurating salpin- 
gitis will be more of degree than of kind. In the abscess forming 
in the abdominal cavity, either as a small pocket in the midst of 
the lymph or as a general abscess of the whole pelvic cavity, the 
absorption is apt to be more rapid than if confined to the Fallo- 
pian tube. 

Cellulitis. — The symptoms attributable to this disease are indis- 
tinguishable from those of peritonitis. The two affections go hand 
in hand, and any attempt to classify their symptoms would only be 
theoretical. As a matter of fact, they cannot be distinguished 
clinically. A simple infiltration of the cellular tissue with inflam- 
matory products would produce no other symptom than possibly 
a feeling of weight and fulness, but this discomfort would be so 
overshadowed by the severe suffering from the peritonitis as hardly 
to be noticed. In those rare cases in which primary abscesses 
occur in the cellular tissue, following or accompanying the puer- 
perium, nothing distinctive is noticed until suppuration occurs, 
and then the symptoms are simply those of septicemia. An attempt 
to classify and compare, for differential purposes, the symptoms 
of cellulitis and peritonitis is of no more than problematic value ; 
it is of no practical benefit. Clinically, the two affections are 
indistinguishable, for the reason that they always complicate one 
another, and their symptoms are so closely interwoven. The 
sym[)toms of the cellulitis, which is mostly secondary, are few and 
unimportant and are completely overshadowed by the far more 
important and severe symptoms of the peritonitis, the primary 
disease. 

Physical Signs. — In an attack of pelvic inflammation there 
is always a fairly regular routine followed, and the results are 
essentially the same, differing only in degree. Every case is in 
this respect a law unto itself, and in no two of them are the Fallo- 
pian tubes and ovaries equally degenerated and distended, nor are 
they always found in the same position. The physical signs are so 



PELVIC INFLAMMATION, 471 

closely interwoven that all the elements must be considered together 
if they are to be viewed to the best advantage. 

Catarrhal Salpingitis. — Physical signs are entirely absent. There 
is no infiljtration of the tube-walls, and no peritonitis or cellulitis, with 
attendant exudate of lymph and infiltration of inflammatory prod- 
ucts. The Fallopian tube is almost, if not entirely, as soft as in 
its normal condition, and if there is any enlargement it is simply 
due to a mild congestion. For practical purposes it may be con- 
sidered that in the average woman of ordinary size the Fallopian 
tube cannot be palpated. Such may be said also to be the case in 
catarrhal salpingitis. 

Hydrosalpinx. — In this form of the disease the uterus may or 
may not be freely movable. Most frequently it is movable, as the 
Fallopian tube is either not adherent or so lightly so as not to 
affect the womb. The mobility of the uterus in health varies so 
much that it is often difficult to decide whether or not it is 
impaired. Most frequently, both Fallopian tubes are involved, 
although it is no unusual thing to find only one side affected. By 
deep palpation to the sides of the womb a cystic tumor, varying 
in size and shape, will be felt. The tumor is elongated, and can 
be traced with the finger from the side of the pelvis to the uterine 
cornua. It is distinctly felt to be free from the uterus and inde- 
pendent of that organ. Usually, a sulcus can be recognized between 
the two. The examination may simply disclose a large cystic tumor 
wath nothing characteristic about it ; in either case the growth may 
be fixed by adhesions and rendered immovable, or it may readily 
be displaced in any direction. The opposite side may be found in 
the same condition, or the examination may disclose nothing as 
regards its involvement. It is often found in a state of simple 
catarrhal salpingitis. 

Very much the same can be said in regard to that phase of the 
disease in which the tube is distended with blood, as has been said 
of hydrosalpinx. Hematosalpinx has no distinguishing features. 
It differs from hydrosalpinx only in that it is apt to be smaller, 
with thicker walls, and more likely to be adherent, and conse- 
quently immovable. The affection is most usually unilateral, 
and is often complicated on the opposite side by an interstitial 
salpingitis.' 

When the walls of the Fallopian tube are infiltrated with 
inflammatory products and its peritoneal covering involved, an 



472 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

examination of the pelvis will reveal a condition depending upon 
the severity of the attack and the extent of its advance. The uterus 
will be found to a greater or less extent immovable, as well as en- 
larged. It will be adherent in a displaced position or not, depending 
upon its location in the pelvis at the time of the attack of inflam- 
mation. In the milder attacks the Fallopian tubes will be easily 
felt to the sides of the womb as hard, elongated cords, adherent, 
immovable, and extremely painful to the touch. The organ can 
readily be traced to the uterine cornua, and a sulcus may be felt be- 
tween the two. The ovaries will be found about halfway between 
the pelvic wall and the uterus on either side, enlarged, hard, and 
adherent. The size of the tube and ovary, as well as that of the 
uterus, will depend upon the amount of involvement of the cellular 
tissue, but more particularly upon the extent of involvement of the 
peritoneum and the amount of lymph thrown out. A Fallopian 
tube and ovary which together appear in situ to be as large as a 
four-ounce bottle will not infrequently be found, on removal, not 
more than two or three times the natural size : the remainder of the 
bulk is found to have been made up of plastic lymph, which is to 
a great extent destroyed as the adhesions are broken up. The size 
of the womb is also at times more apparent than real, the enlarge- 
ment being also due to the surrounding lymph. For the most part, 
however, the womb is actually enlarged by the inflammatory infil- 
trate into its walls, brought about by the primary endometritis. As 
often as not the uterine appendages are displaced, and may be found 
in any part of the pelvis. Both tubes and both ovaries have been 
observed on the same side, the one ovary being displaced in some 
manner, and found directly adherent on top of the opposite one. Not 
infrequently, when the uterus is retrodisplaced, either one or both 
appendages will be found posterior to this organ, and so high up 
as to be out of reach ; they are consequently often overlooked. 
The disease is generally bilateral, and the same condition can be 
felt on both sides ; at times, however, it is only unilateral. When 
there is acute involvement of the whole of the peritoneum on the 
floor of the pelvis, as well as of the connective tissue underlying 
it, a sensation of fulness in all directions will be felt, its hardness 
depending upon the amount of infiltration and the chronicity of 
the case. 

Should the tubes and ovaries be distended with pus, they will 
be found on palpation in much the same condition as that just 



PELVIC INFLAMMATION, 473 

described. If the pus be present in considerable quantities, the 
masses may fluctuate or give to the touch a sensation of softness, 
and in very exceptional cases may feel not unlike ordinary cysts. 
Should small abscesses exist in the lymph or connective tissue 
surrounding the uterine appendages, they cannot be detected. 
When these intraperitoneal abscesses extend and involve a con- 
siderable part of the pelvis, advancing even into the connective 
tissue, the whole pelvic vault conveys a hard, board-like feeling to 
the examining finger — a condition which extends as far as the finger 
in the vagina can explore. It is not uncommon to find an infiltrat- 
ing ring higher up about the rectum. This ring is due to connec- 
tive-tissue infiltration, and does not usually break down into sup- 
puration. Through the abdominal walls a hard mass of no definite 
shape or consistency can at times be felt, which is made up for the 
most part by adherent intestines and omentum. Ordinarily, the 
infiltrating masses cannot be felt through the abdominal walls 
except with the patient under the influence of ether : only in cases 
of pelvic abscess do these large irregular masses rise into the 
abdominal cavity high enough to be readily felt by abdominal 
palpation. 

Diagnosis. — The establishment of the diagnosis of pelvic 
inflammation is difficult or not according to the stage at which 
the disease has advanced and according to the virulence of the 
infection. 

Catarrhal Salpingitis. — It is not possible to diagnose this form 
of disease except by inference. Symptoms are so slight as not 
particularly to call the patient's attention to her pelvic organs 
unless she be already suffering from endometrial disease ; in this 
case the symptoms caused by the infection of the uterine cavity will 
so greatly overshadow^ all those of the salpingitis that she will have 
no cause to even suspect that her Fallopian tube is becoming 
involved. Even should the disease be suspected, there is no way in 
which the suspicion can be verified, for the reason that the Fallo- 
pian tube can only be palpated in exceptional cases, and even 
should it be felt, the changes in its tissue are so slight that they 
could not be distinguished by the touch. Later on, when sterility 
is demonstrated or a hydrosalpinx is discovered, the relation of 
cause and effect may be seen. The sterility may, however, be caused 
by intra-uterine disease, in which case, until the specimen be 
actually under the microscope, it is not always possible to make the 



474 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

diagnosis, even by inference. An element of doubt would exist 
under the most favorable circumstances, rendering speculation or 
theory absolutely useless for practical purposes. 

Hydrosalpinx, — It is always possible to come to the conclusion 
in this phase of the disease that there is a tumor present in the 
pelvis which does not belong there. It may even be possible in 
some cases to say positively that this form of the disease exists. 
Theoretically nothing should be easier, but practically many ele- 
ments combine to defeat the desired result. The tumor caused by 
a hydrosalpinx is mostly unilateral, and will be found in the posi- 
tion which should be occupied by the Fallopian tube and ovary. 
If a tumor be found in this position and its character be doubtful, 
an examination with the patient under ether will often clear up the 
doubtful points. The walls of this neoplasm are thin and the tumor 
fluctuates. The amount of fluctuation will depend largely upon the 
size of the growth, the consequent thinness of its walls, and upon 
the number and density of its adhesions. At times it is entirely 
free from adhesions, and is as freely movable, within the" limits of 
the mobility of the Fallopian tube, as would be an ovarian cyst. 
Should the tumor be a large one, it will assume a rounded shape 
not unlike a cystic ovary. On the other hand, when the tubal dis- 
tension is limited, the resulting tumor will retain the elongated, 
tortuous shape of the Fallopian tube. The principal diseases that 
may be mistaken for this condition are small ovarian cysts, small 
parovarian cysts, hematosalpinx, and extra-uterine pregnancy. In 
hydrosalpinx the main features in the diagnosis are the elongated, 
sausage-like shape of the tumor ; the fact that it can be traced to 
the uterine cornua at the position where the tube would naturally 
be found ; the presence of the ovary independent of the tumor ; 
and the fact that it is a cystic growth. The ovarian cyst is always 
rounded in shape, and there is no connection whatever between it 
and the uterus. The parovarian cyst is apt to be much less movable, 
and never has the elongated shape of the hydrosalpinx ; neither has 
it any connection with the uterus such as described. 

It is not possible to distinguish hematosalpinx by the physical 
signs, and the symptomatology is too unreliable to be trusted. The 
fact that the blood-tumor is more liable to be adherent is not suf- 
ficiently practical to be of much benefit. Extra-uterine pregnancy 
can generally be distinguished by its symptomatology and by watch- 
ing its behavior as it grows. It is probable that more frequent mis- 



PELVIC INFLAMMATION. 475 

takes will be made in the case of small parovarian cysts than any- 
thing else. After all has been said, failure oftener than success 
results in an attempt to diagnose hydrosalpinx. 

Hematosalpinx. — What has been said in the case of hydrosalpinx 
is equally true of this disease. The same characteristics of the 
tumor exist, excepting that the hematosalpinx is not apt to become 
so large. However, as there are many cases of small hydrosalpinx, 
this point has no particular value. The tumor is elongated ; it is 
connected at the uterine cornua, as is the case with the normal 
Fallopian tube ; it fluctuates more or less satisfactorily ; if the dis- 
tension be only slight, this sign is worthlc">s. The question of 
adhesions is also of dubious advantage, as an^ of the products of 
pelvic inflammation are almost certain to be adherent. The one 
sign which may be of advantage in the diagnosis of either hemato- 
salpinx or hydrosalpinx is the division of the elongated tumor into 
compartments, or an apparent attempt in this direction. Tlie 
healthy Fallopian tube is so divided, and it is frequently the case 
that a tube distended by fluid contents has two or more compart- 
ments. These can at times be appreciated by the touch, and in case 
they are a diagnosis can probably be arrived at. 

Interstitial Salpingitis and Ovaritis. — Nothing is more deceptive 
than the symptomatology in pelvic inflammations. A woman may 
present herself complaining of all the symptoms of diseased, dis- 
organized appendages, and yet an examination fail to establish such 
a diagnosis. A patient may give a history of having been married 
for some years and of having had one or more children. She has 
remained in good health until in her last confinement or miscarriage, 
when she has had septic trouble, indicated by a swollen and painful 
abdomen, together with fever. Or her trouble may have begun 
with a well-marked attack of gonorrhea. From this time until she 
consults her physician she is not in good health. Pain is a con- 
stant companion, being referred to the iliac regions or the back. 
There is pain on coitus, defecation, riding in the cars, walking, or 
sitting down, and under any circumstances which will cause a dis- 
placement of the pelvic organs. The menstrual function, which was 
originally normal, is now profuse and irregular. Muco -purulent 
discharges exist ; the patient suffers from chilly feelings at times, 
and loses flesh. The history in such a case is complete, and if the 
symptoms alone are depended upon to make the diagnosis, the most 
skilled physician will probably be often led astray. Such patients 



476 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

continually report themselves, and a bimanual examination even 
under ether fails to confirm a diagnosis of pyosalpinx or of chronic 
interstitial salpingitis, although the entire pelvis may be exquisitely 
tender to the touch. In such cases, where the abdomen has been 
opened for exploration, the peritoneum and cellular tissues have 
frequently been found to be healthy, as far as a macroscopical exam- 
ination could determine. It is altogether unjustifiable to send a 
patient to the operating-room, presumably suffering from the results 
of pelvic inflammation, without first having made a thorough and 
searching examination of the pelvic organs by bimanual palpation ; 
and if there is any doubt as to the existence of any lesion, the 
examination should be made with the patient under ether. The 
combination of the symptomatology and physical signs will gene- 
rally succeed in establishing a con-ect diagnosis in these diseases. 
However, unless one of the Fallopian tubes or ovaries can be pal- 
pated, and plainly demonstrated as being enlarged and diseased, the 
diagnosis cannot be said to have been established. The symptoms 
can generally be traced to a labor, a miscarriage, or an attack of 
gonorrhea. A very large number of the patients have had an 
" inflammation in the stomach," or give a history of having had 
typhoid or malarial fever in or following the puerperium ; their 
symptoms have dated from or about this time ; sterility is a prom- 
inent and constant feature. The principal indication of the under- 
lying trouble is the pain and the disordered menstrual function, and 
not infrequently there is a history of one or more attacks of peri- 
tonitis. A vaginal examination usually discloses an adherent and 
more or less immovable uterus. In a goodly number of cases, how- 
ever, the uterus will not be found fixed, but movable within certain 
limits. An attempt to displace the womb will elicit pain, whether 
it be adherent or not, the pain being caused for the most part by the 
dragging upon adhesions, either those involving the uterus or those 
encircling the Fallopian tube and ovaries. The pain will be greater 
or less in proportion as the inflammation about the parts has 
subsided. 

To the right or left on both sides of the womb the Fallopian 
tubes and ovaries may be felt. The tube is enlarged, thickened, 
and adherent. Attempts at displacing it result simply in causing 
pain ; the whole pelvic vault is tender when the inflammation has not 
subsided. The Fallopian tubes will be felt as elongated, tortuous 
bodies in the p)osition of the normal organs, extending from the 



PELVIC INFLAMMATION. 477 

side of the pelvis to the uterine cornua. In some cases the ovary, 
from the fact that it is prolapsed to a lower level than that of the 
tube, forms the greater bulk of the mass presenting to the examin- 
ing finger ; slightly deeper palpation will, however, usually disclose 
the elongated tube. Occasionally it happens that the uterus is retro- 
displaced, and the appendages are one or both of them twisted pos- 
terior to the fundus, and, unless the i3atient be under the influence 
of ether, cannot be distinguished. So closely attached are the 
appendages at times to the womb that the whole mass appears as 
one body, and it is only by the irregularity of the mass and the 
existence of a sulcus between the diseased aj)23endage and the womb 
that the true condition can be distinguished. An examination by 
the rectum which permits of the examining finger being passed pos- 
terior to and above the uterus and broad lio-aments will often decide 
these points, where no definite conclusion could be arrived at by the 
combined vaginal and abdominal touch. In the acute condition, 
where the appendages are surrounded by and buried in masses of 
peritoneal lymph and the cellular tissue is involved, they will appear 
to be of great or indefinite size. The whole vaginal vault may be 
so hard and board-like that it will be impossible to distinguish the 
appendages through the general mass of lymph. In the more 
chronic form, when the lymph and cellular exudate have in great 
part been absorbed, the tube may present itself only as large in 
diameter as an ordinary lead pencil. It is not very probable that 
there will be a failure to diagnose the disease, excepting where it 
has undergone suppuration and assumes more or less the charactei- 
of a cyst. These enlarged and thickened tubes and ovaries, densely 
adherent and often surrounded by masses of peritoneal lymph and 
cellular exudates, taken together with the history and symptoms, 
can hardly be misunderstood. There are few conditions for which 
this disease is likelv to be mistaken. 

Every woman suffering with the lesions of a pelvic inflamma- 
tion is liable from time to time to have the inflammation recur. 
Frequently the inflammation never leaves the parts, but remains 
as a low-o^rade chronic disease, readv to relio-ht into an acute 
exacerbation on the slightest pretext. In other women it sub- 
sides entirely and the parts become quite free from pain. In 
such a case there is less likelihood of recurring acute attacks, but 
yet they do occur. A woman carrying diseased tubes and ovaries 
due to pelvic inflammation may be confined to her bed as often 



478 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

as three or four times a year, for from two to eight weeks at each 
attack. Usually the recurrence is not so severe, and may not hap- 
pen oftener than once every year or two ; others only last a few 
weeks, frequently not even confining the woman to bed. Exposure 
to cold, excessive indulgence in coition, violence on the part of the 
husband, working tread-machines, hard work of a hundred and one 
different kinds, generally determines the exacerbation. During the 
menstrual period the women are peculiarly liable to these attacks. 
The physiological congestion of menstruation may very readily be 
turned into a pathological condition, and an inflammation result. 
Women afflicted with pelvic inflammations frequently suffer from 
attacks of apparent peritonitis which simulate to a great degree the 
true inflammation. The abdomen and pelvis at the time of the 
examination are found to be exquisitely tender, and not infre- 
quently an investigation is rendered impossible. By persisting 
firmly but gently, at the same time calling the patient's attention 
to some other object, a pelvis and abdomen which would barely 
tolerate the approach of the hand may be brought to bear, with- 
out any complaint from the patient, a very free amount of manip- 
ulation. The hysterical element in these cases of long suffering is 
oftentimes great, and it must always be taken into consideration in 
estimating the amount of pain. 

Pyosalpinx and Ovarian Abscess. — Should suppuration intervene, 
there is at once added the element of septicemia. The tube may 
contain but a few drops of pus, in which case the only additional 
aid to the diagnosis would be in the special symptoms produced by 
the absorption of the pus. Following confinement or miscarriage, 
a woman may have a slow and unsatisfactory " get up," or she may 
not get up at all. Her temperature remains in the neighborhood 
of 100° F., while her pulse-beats continue at about 100 or more. 
She has no appetite, suffers with pain in the lower part of the 
abdomen, sleeps restlessly, and has occasional creepy feelings. This 
condition keeps up for months, with a progressive loss of flesh — 
slight, it is true, but steady. An examination reveals a mild form 
of pelvic inflammation, with the usual lesion of the appendages. 
This condition, taken in connectioil with the history, fairly estab- 
lishes the presumption that pus is present if all other possible 
sources of suppuration be excluded, although it is impossible to 
detect any signs of it by the vaginal examination. Should pus 
accumulate in any great quantity, the Fallopian tube soon distends, 



PELVIC INFLAMMATION. 479 

and may at times reach the size of a large sausage. Should the 
suppuration occur in the tube, in the lymph around the tube, or in 
the ovary, there would be little if any difference in the result. 
Wherever it is located, if the quantity be sufficiently large, the pel- 
vic tumor fluctuates or the whole mass presents a semi-soft or boggy 
feeling. Not infrequently the fluid portion of the suppurating con- 
tents is absorbed altogether, leaving the tube filled with a cheesy 
material which may remain indefinitely and without causing any 
particular disturbance, other than by the mere presence of a foreign 
body in the pelvis. When such a case has been complicated by an 
inflammation of the peritoneum, the same condition may remain, 
and the patient suffer just as much as though" the fluid had not 
been absorbed. Fallopian tubes of this character become at 
times the size of large sweet potatoes. It is exceedingly difficult 
frequently to distinguish pyosalpinx and ovarian abscess from 
some other pelvic diseases, notably extra-uterine pregnancy or 
abscess located in other parts of the pelvis. No two pelvic dis- 
eases are so frequently mistaken for one another as pyosalpinx 
and ectopic gestation. A careful study of the history of the patient 
is at times essential to a determination of the difference, and is of 
more value than the physical signs. Extra-uterine pregnancy pro- 
duces symptoms which, if they can be elicited, are characteristic, 
but they are so frequently modified that it is difficult to distinguish 
them. The pain in the two diseases may be essentially alike, at 
least so far as a description of it can be elicited from the patient : 
the physical characteristics of the cysts are not dissimilar, both being 
semifluctuant, located in the same position, of the same shape, and 
of about the same size in the early stages of the pregnancy. The 
uterus is enlarged in both, the menstrual function is disordered, and 
the breast and stomach symptoms are not infrequently similar in 
either case. The casting off of the decidual membrane is by no 
means a constantly demonstrable feature of the extra-uterine preg- 
nancy. The progressive growth of the tumor, if the patient be 
kept under observation sufficiently long, is very suggestive, if not 
positive evidence, of ectopic gestation. 

Suppuration confined to the Fallopian tubes or ovary is more apt 
to give a circumscribed tumor than suppuration in the plastic lymph 
or connective tissue. In the case of a pyosalpinx or ovarian tumor 
the tube-sac can be felt as a distinct body, adherent and immovable, 
it is true, but still a circumscribed tumor, with a distinct sulcus 



480 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

between it and the uterus. The true pelvic abscess is quite the 
reverse, and oftentimes nothing definite can be made out, only a 
general fulness occupying the pelvis more or less, without any 
definite limitations, and so involving all the pelvic organs that 
none of them can be distinguished. In either case there may or 
may not be fluctuation. 

Cystic tumors are distinguished from a pyosalpinx or ovarian 
abscess by the thickness of the walls of the latter, the more boggy 
feel, the septic symptoms, and the history. A tubal and ovarian 
mass confined to the pelvis, fluctuating, with thick walls, densely 
adherent, painful on examination, with a history of sepsis, can 
hardly be mistaken for anything but a tubal or ovarian abscess 
unless it be an extra-uterine pregnancy. 

Peritonitis. — Pelvic peritonitis in women rarely if ever exists 
without a pre-existing endometritis and salpingitis; among the 
exceptions it has been noted that an appendicitis has occasionally 
been the source of the disease. These cases are rare, and althouoh 
the vermiform appendix has not infrequently been found in the pel- 
vis perforated and adherent to the Fallopian tube and ovary, with 
abscesses in the surrounding lymph, yet it is always a question as to 
whether the inflammation started in the Fallopian tube or in the 
vermiform appendix. The diagnosis w^ould rest in such a case 
almost entirely upon the history. Wherever the disease originates, 
the result has been observed to be the same — a salpingitis and a 
peritonitis. When the symptoms and diagnosis of salpingitis have 
been considered, about all that can be said about peritonitis has been 
told, for the reason that inflammation of the Fallopian tube and the 
symptoms arising from the combined disease originate mostly in the 
peritonitis. A salpingitis uncomplicated by an inflammation of the 
peritoneum would give rise to but few symptoms. Such is the case 
with catarrhal salpingitis, and even with its resultant lesion, hydro- 
salpinx. It is the peritonitis accompanying the salpingitis that 
causes the formation of the large masses of lymph, the subsequent 
adhesions and immobility of the organs, the pain, the leucorrheal 
discharges (in part), the disordered menstrual function, and, in fact, 
all the prominent symptoms of the disorder. The extent to which 
peritonitis exists in any given case is oftentimes problematic and 
can only be guessed at. The whole pelvis may be involved or the 
lesion may be limited to a fractional part of it. The less of the 
serous membrane involved, the less will be the pain and the fewer 



PELVIC INFLAMMATION. 481 

the adhesions. Iii the acute stage of the inflammation lymph is- 
thrown out about the parts affected, and the contiguous serous sur- 
faces become attached to one another. These points can be palpated 
and a fairly clear idea of their extent obtained. The exudated 
lymph may be confined about the Fallopian tubes or ovaries, one or 
both, or it may be found that the loops of intestine and omentum 
overlying the pelvic inlet have become involved, and are adherent 
to each other and to the pelvic organs. This lymph exudation and 
adhesion is Nature's method of heading off an inflammation of the 
serous membrane, and it is interesting to note the repeated and con- 
tinued exudation, as the inflammatory process overcomes the areas 
it has first attempted to protect, knuckle after knuckle of the intes- 
tine becoming glued together in front of the advancing infection, 
until the lymph has finally effectually stayed its progress. The 
result in bad cases is an indurated mass in the lower portion of the 
abdomen, overlying and dipping down into the pelvic inlet. With 
the patient's history and the presence of such a tumor it is not hard 
to realize the relation of cause and effect. Such a mass is usually 
more or less tympanitic and immovable. Under treatment, unless 
suppuration has occurred, these masses disappear to a great extent, 
leaving the intestine and omentum adherent, it is true, but as the 
lymph has been absorbed the mass has lost its hard, indurated cha- 
racter, and has assumed more nearly the usual characteristics of the 
soft intestine. In fact, as a distinct tumor the whole mass generally 
disappears ; in some cases, on the other hand, it remains to the end. 
Should suppuration occur, this is the usual course. Suppuration of 
the tubal contents is very common, and is not infrequently associated 
with a breaking down of the peritoneal lymph surrounding the 
appendages at several points, resulting in the formation of one or 
more small abscesses about the appendages. These surrounding 
abscesses are commonly spoken of as occurring in the connective 
tissue, but they arise distinctly from and in the plastic lymph. It 
is not possible to diagnose their existence prior to an operation unless 
they spread and become large enough to overshadow the tubal or 
ovarian abscess. Even then it is more than probable that they 
would be mistaken for an abscess located in the Fallopian tube or 
ovary. As a matter of fact, they do not often become so very large, 
unless the infection has travelled fast and overcome the resistance 
of the obstructing lymph, forming a large pelvic abscess^intra- 
peritoneal as a matter of fact, as are almost all the pelvic abscesses. 

31 



482 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

It is possible at times to say that the pelvic abscess exists, but 
usually the distinction can only be made between a true pelvic 
abscess and a bad case of pyosalpinx by an experienced diagnostician, 
the points of difference being determined by the physician's per- 
sonal experience and delicacy of tactile sense. As a rule, where 
there is a large indurated mass rising into the abdominal cavity free 
pus will be found in the pelvis ; but this is by no means a sure 
sign. When the pelvis is full of free pus, the vaginal vault is apt 
to give a sense of fulness and induration in all directions, as if the 
whole pelvis were filled with a solid mass. This feeling extending 
more or less over the whole of the pelvic floor, none of the pelvic 
organs can be outlined ; the uterus is fixed in its position, whatever 
that may be. Fluctuation may or may not be detected ; frequently 
the pelvic floor is so hard and indurated that this sign is very uncer- 
tain. That a bad pelvic inflammation has existed, and that sup- 
puration has occurred, are, usually unmistakable. Anything fur- 
ther in the line of an exact diagnosis must rest on the particular 
features of the special case and the physician's dexterity and 
experience. 

Cellulitis. — What has been said about peritonitis is also true of 
cellulitis. A few cases of this disease may arise in puerperal 
patients by transmission of the inflammation along the walls of 
the lymphatics and suppuration of the cellular tissue. Such cases 
are rare, and if they do exist cannot be diagnosed from the intra- 
peritoneal pelvic abscesses, those which arise within the peritoneal 
sac from breaking down and suppuration of the peritoneal lymph 
and exudates. Inflammation of the cellular tissue always accom- 
panies a severe peritonitis, and the two are indistinguishable from a 
diagnostic point of view. The cellular tissue in the broad ligaments 
becomes involved in the course of a pelvic inflammation, the result 
being a distension of the ligament by exudates and a destruction of 
the cellular elements by the inflammatory process. As the inflam- 
mation subsides, the ligament is contracted or destroyed, which re- 
sult may be recognized at a subsequent investigation after the case 
becomes a chronic one. 

The usual points of distinction between a pelvic cellulitis and a 
pelvic peritonitis, as formulated and compared in all works on gyn- 
ecology, are misleading and worthless. It is utterly impossible for 
any one to make a practical distinction between these two phases of 
a common disease, and the formulae as given only tend to complicate 



PELVIC INFLAMMATION. 483 

the understanding of what is possible and what is clinically true. 
The difference is purely theoretical ; practically and clinically they 
are part and parcel of the same disease — viz. pelvic inflammation. 
The cellular tissue rarely suppurates except in conjunction with the 
suppuration of the peritoneal exudates. When it does break down, 
it cannot be distinguished, short of operation, from other forms of 
pelvic abscess. The disease, except in the form of an abscess, never 
exists as a chronic condition ; its resultant contraction of the broad 
ligament may exist and be recognized, but the cellular inflammation 
has ended in the acute attack by a destruction of the connective 
tissue. 

Prognosis. — The prognosis of pelvic inflammations is variable 
according to the phase which the disease assumes, the character of 
the infection, and the manner in which it is treated. It may end in 
complete recovery, permanent crippling, or death. Catarrhal sal- 
pingitis usually undergoes a spontaneous cure, at times with a com- 
plete restoration of the tissues to their normal condition of health, 
oftener after the destruction and desquamation of the ciliated epi- 
thelium. Should the Fallopian tubes become occluded at any point, 
sterility is an accomplished fact, and either a hydro- or hematosal- 
pinx a possibility. Even without occlusion of the Fallopian tube 
sterility is frequent, from the fact that the cilia, whose function it 
is to carry the ovum toward the uterine cavity, are lost, and the 
ovum may lodge at any point throughout the length of the tube, 
and there perish, or it may be so long delayed in its passage as to 
be too enfeebled to become impregnated when it meets the sperma- 
tozoid. Extra-uterine pregnancy is commonly accompanied by a 
history of long-standing sterility, and it is this disease which is 
supposed to be the cause of the misplaced conception. The ovum, 
lodging in the Fallopian tube, becomes impregnated by the sperm a- 
tozoid, and, not being able to escape into the uterine cavity, develops 
in the tube. 

If the ends of the tube remain patulous, there is no great danger 
of an accumulation of the excretions, but should they become closed, 
a hydrosalpinx is almost inevitable, unless the excretions have 
ceased or the absorptive powers of the tube are equal to the occa- 
sion. Hydrosalpinx is not fraught with any great danger to life, 
and unless it becomes complicated by pelvic peritonitis is not liable 
to cause any great discomfort to the patient. It would act in much 
the same manner as would small unadherent ovaries. Should peri- 



484 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

tonitis supervene and adhesions result, the patient would suffer from 
long-continued pelvic distress and pains, and would be liable to sec- 
ondary attacks of peritonitis. Hematosalpinx acts in much the same 
manner, it being more liable to inflammatory complications. Inter- 
stitial salpingitis always threatens life, for the reason that it is always 
complicated by pelvic peritonitis. The affected Fallopian tube is 
always occluded, either throughout its course or at its distal end, by 
the fimbria becoming adherent to the ovary. If both tubes are so 
affected, sterility is certain and permanent. The amount of danger 
to life will depend in great part upon the amount of the complicat- 
ing peritonitis and cellulitis. If the infection has been a particu- 
larly virulent one, and has escaped out of the fimbriated end of the 
Fallopian tube before Nature has had an opportunity to build up a 
wall of obstructing lymph, it will probably infect the larger part of 
the pelvic cavity before its course can be stayed : should it escape 
into the abdominal cavity, a general peritonitis is likely to result, 
and death follow. Puerperal septic infection is more liable to have 
this termination than gonorrheal infection, although the latter claims 
its fair share of victims. Women who have acquired interstitial sal- 
pingitis, and in whom the disease has become chronic, are very liable 
to suffer from recurrent attacks of peritonitis. These attacks occur 
more or less frequently and with more or less severity. At any 
time they may develop into a general peritonitis and end fatally, or 
suppurative changes may be set up w^hich will require a surgical 
operation to save tlie patient's life. As long as they remain qui- 
escent they cause little more damage than that brought about by the 
constant pain. On the other hand, they may render the patient's 
life miserable, the only prospect of relief being either their removal 
or the menopause. It is an undoubted fact that the change of life, 
when it becomes established, brings relief and cure to many of these 
women : the disease, however, frequently accompanies delayed men- 
opause, and is most probably the cause of the delay. Spontaneous 
cures other than by the menopause are rare ; at the same time, it 
cannot be successfully disputed that such is the case in a small pro- 
portion of cases. 

Pyosalpinx and ovarian abscess are much more liable to be accom- 
panied with recurrent attacks of peritonitis, and are consequently 
more serious lesions, than any of the other forms of disease of the 
uterine appendages. Usually they mean lifelong invalidism to the 
patient if she escapes primary death. Death is often the least 



PELVIC INFLAMMATION. 485 

of the consequences of this lesion. The patient drags along in a 
miserable condition of sepsis, with its resulting fever, hectic, and 
emaciation, until she dies of exhaustion or until the abscess has 
succeeded in finding an outlet into some of the neighboring vis- 
cera: even then her last state is hardly better than her first. 
Should the rupture occur into the uterus, a spontaneous cure may 
result, or the tube may refill and discharge repeatedly, all the while 
with the chance of its calibre becoming permanently closed. Should 
leakage take place from the fimbriated end into the peritoneal cav- 
ity, a general suppurative peritonitis may result, with its usual end- 
ing. Should, on the other hand, the pus find its way through the 
bowel or bladder- walls, a sinus will be formed which will most prob- 
ably refuse to yield to any treatment short of surgical. This disease, 
at the best, means a lifelong invalidism to the patient, and is a con- 
stant menace to her life. Much the same may be said of abscesses 
in the pelvis due to peritonitis and cellulitis. Those occurring pri- 
marily in the cellular tissue, following labor, are said to run a rapid 
course, .and generally end in death, unless they are recognized and 
provision made for the discharge of the pus. Even with this pre- 
caution many cases die. The same may be said to be true in a less- 
ened degree of ordinary pelvic abscesses, although this form is apt 
to give sufiicient time in which the physician may act. If these 
abscesses are projDcrly opened and drained, the chances for the 
patient's recovery are good. Should they be neglected, the woman 
will either die from the exhaustion of septicemia, or the abscesses 
will open spontaneously in one of the many ways already described. 
Frequently it is impossible to obtain healing of the sinus tracks 
made by the burrowing of the pus from these abscesses, and, in 
spite of the fact that the abscess-cavity is emptied, the purulent 
discharge continues indefinitely, the patient eking out a miserable, 
lingering existence, only to die finally of exhaustion. 

Teeatment. — The treatment of pelvic inflammation is satis- 
factory in accordance with the stage of the disease and the manner 
in which it is attacked. It is one of the preventable diseases, and 
if the infection is taken in hand in time it is perfectly amenable to 
treatment. After it has gained full headway it is only possible to 
ameliorate the symptoms, and finally, if necessary, to remove the 
resulting lesions. The treatment is prophylactic, palliative, and 
curative. 

The prevention is embraced in the treatment and cure of the 



486 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

infection while it is still confined to the vagina and to the uterus. 
If the vaginitis or endometritis be taken in time, the disease may 
readily be stayed and a pelvic involvement prevented. This is 
true of the majority of cases, but it must be borne in mind that 
there is a certain proportion, of puerperal patients particularly, in 
whom the infection travels so rapidly that the serous membrane is 
involved before the physician has time to realize that the danger is 
seriously threatened; this Is also true of a small proportion of 
gonorrheal cases. In spite of the existence of these exceptional 
cases, it is a lamentable fact that the majority of pelvic inflamma- 
tions are preventable, and that the attending physician is only too 
frequently responsible — if not for sins of commission, at least for 
sins of omission. Should a patient be suffering from gonorrhea, 
it should always be attacked vigorously and scientifically, ever 
bearing in mind that the mildest case may result in irreparable 
damage to the pelvic peritoneum, and may even result in death. 
The vagina must be exposed throughout its whole extent and 
thoroughly treated, and, if the endometrium becomes involved, 
it should receive equally prompt attention. The methods of 
treatment of these troubles will be found fully expounded else- 
where. Infection starting in the uterus from a post-puerperal 
sepsis should never be neglected. General treatment as it is 
too often indulged in by the physician is only playing with fire, 
and, like the proverbial child, his fingers are frequently burned. 
Every woman who after a labor or a miscarriage has an elevation 
of temperature and pulse should at once have an antiseptic vaginal 
douche. Should the temperature and pulse not fall to normal or 
thereabouts after several such douches repeated at half a dozen 
hours' interval, the syringe should be carried to the fundus of the 
uterus and a similar injection made into the cavity of the womb. 
If after repeating this treatment several times in the twenty-four 
hours the patient's symptoms have not subsided or become markedly 
better, the physician is committing an inexcusable blunder if he 
does not thoroughly curette the whole of the cavity of the womb, 
irrigate it, and render it as aseptic as possible. Should all cases of 
gonorrhea and puerperal sepsis be treated on these common-sense 
principles, pelvic inflammations in women would be far rarer than 
they are at the present time. To just the extent of propriety and 
intelligence with which the physician treats these cases will he have 
the fewer cases of pelvic trouble originating in his practice. 



PELVIC INFLAMMATION, . 487 

Should the disease once invade the Fallopian tubes, it is beyond 
local treatment, and it is largely a matter of chance as to how far 
it will spread and how much damage it will succeed in doing before 
being brought under control. In Nature's hands lie the most 
effective weapons for combating the inflammation, and practically 
all the physician is able to do is to aid by placing the patient under 
the most favorable circumstances possible, and giving Nature every 
chance to succeed in her fight. In the acute form of the disease 
two objects must be kept constantly in mind : the force of the 
inflammation must be weakened in every possible way, and Nature 
must be left unhampered to wage the fight. As in every inflamma- 
tion, rest is absolutely essential. By " rest " is meant sexual as well 
as physical quietude. The woman should be placed in bed, and 
kept there until the attack has subsided : sexual intercourse should 
not only be absolutely prohibited, but even the approach of the 
husband, sufficient to excite pelvic congestion, must be carefully 
guarded against. Many an attack of threatened pelvic inflamma- 
tion has been precipitated by indiscretions in these directions. 
During the menstrual periods the greatest caution is necessary. 
The congestion incident to this period is physiological, but in a 
patient who is threatened with a pelvic inflammation, or in one in 
whom the inflammation is actually in existence, it may readily be 
converted into a pathological state and the inflammatory attack be 
precipitated. Rest cannot be perfectly obtained if the bowels, espe- 
cially the sigmoid flexure and rectum, are allowed to become over- 
loaded with fecal matter. The hard, scybalous masses which form 
under these circumstances are a continual source of irritation. 
Woman is naturally a constipated animal, but these masses are the 
more apt to form, inasmuch as the peristaltic action of the bowel is 
in great part inhibited by the inflammation of its serous coat. It 
becomes a matter of prime importance, then, to empty and keep 
the lower bowel free from accumulations of fecal matter. Absolute 
rest having been secured, depletion is next to be obtained. The 
intestinal tract is the most adapted of all sources for bringing about 
this result. The free use of some drastic purgative will best con- 
serve the purpose. Possibly some one of the magnesium salts is the 
best drug for this use. Magnesium sulphate, administered in doses 
of a teaspoon ful, dissolved in a small quantity of water, a saturated 
solution being preferable, each hour, for from six to ten doses, will 
usually produce the desired result. Should the salts be rejected, as 



488 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

they sometimes are, any other purgative may be substituted. The 
bowel will incidentally be emptied of its fecal contents, and large and 
repeated watery stools will result. The amount of dam.age done by 
friction set up by the peristaltic action of the intestines will be far 
outweighed by the good done by the general and local depletion. 
The watery stools are produced by drawing on the fluid element in 
the blood-vessels from all over the body, but particularly from those 
near and connected with the intestinal tract. The withdrawal of 
this fluid lessens the blood-supply to the inflamed parts, and at the 
same time creates such an intense demand for fluid in the vascular 
system that the inflammatory exudates are taken up the quicker. 
A pelvic inflammation which is just starting is often cut short by 
this procedure, and it is at times surprising to see the amount of 
relief experienced by patients, as demonstrated by the cessation of 
pain and the absence of the anxious expression of the countenance. 
One free movement of the bowels will in some cases act more 
promptly in this direction than will several hypodermics of mor- 
phia. There are certain cases, however — usually those who have 
been suffering for some time before having come under treatment — 
whom the treatment will not relieve, it matters not how many times 
the bowels are moved. Inflammations in the pelvis are like inflam- 
mations in any other part of the body: if depletion is not applied 
until the trouble is chronic, there is little to be expected from it ; in 
the acute stage it is invaluable. 

It is not possible to keep up purgation indefinitely, and especially 
if the patient be not particularly strong, care and discretion must be 
used in this direction. It is well, if the woman can stand it — and 
the vast majority of them are able to do so — to procure one good 
purgation consisting of six to ten free watery stools. After this the 
bowels may be kept soluble daily by administering a laxative once 
in the twenty-four hours. After purgation hot vaginal douching is 
perhaps the best method of securi g continued depletion of the pel- 
vis. If the douches be given properly, they will go a long way 
toward effecting a speedy reduction of the inflammation ; if they 
are given improperly, they will only render matters more compli- 
cated. Douches as usually employed by the profession at large were 
far better done away with altogether, as they only tend to render 
the pelvic inflammation worse. The primary effect of the applica- 
tion of hot water is to cause a congestion and the determination of 
large quantities of blood to the parts, as any one can demonstrate 



PELVIC INFLAMMATION. 489 

for himself by placing his hands in hot water and noting how puffy 
they become. If the water be sufficiently hot and the hand be 
held in it long enough, the tissues will begin to shrink, and what 
is commonly known as the "washerwoman's hands " will be the 
result. This condition is brought about by the secondary action of 
the hot water ; that is, contraction of the soft tissues. This con- 
traction renders the calibre of the blood-vessels smaller, and drives 
a very considerable proportion of the blood out of the parts so 
affected. The more profoundly this action is produced and the 
longer it is kept up, the more complete and lasting will be the 
depletion. It is this secondary effect of the hot water that it is 
desirable to produce in the pelvis. The more thoroughly the blood 
is driven away from the parts, the sooner will the inflammation 
subside ; the more frequently the action is brought about, the sooner 
will the blood-vessels acquire sufficient tone to limit the amount of 
blood they will hold and its powers of exudation. For the success- 
ful accomplishment of this object there are a few rules which it is 
imperative to keep in mind and carry out: The water must be hot, 
from 100° to 110° F., and to be sure that it is of this temperature 
a thermometer should be used. The water must be of sufficient 
quantity to produce the desired secondary action ; for this purpose 
at least a gallon should be used at each injection. It must be 
applied directly and continuously to the parts to be affected ; for 
this purpose the patient should lie in the recumbent dorsal position 
while the douche is being administered. It is important that this 
rule be observed, for the reason that should the woman assume 
a crouching or sitting position all of the water runs away as quickly 
as it is injected, barely coming in contact with the vaginal vault, 
the very part which it is desirable to reach. With the woman 
lying flat upon her back and the knees drawn up, the posterior 
portion of the vagina will be distended with water, and there will 
always be a residual amount in itu, which is constantly bathing 
the parts and is kept at the proper temperature by the continued 
injection. The douche should occupy from fifteen to tw^enty 
minutes in its application, and can best be taken in the bath-tub, 
if the patient is able to be up and about, and is forced to use it 
without the aid of a second person. The syringe, of whatever 
kind, used must have a hard-rubber nozzle, as metal, being a good 
conductor of heat, will burn the parts if the water is used as hot 
as is needed. These douches may be administered two or three 



490 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

times a day, and may be continued for an unlimited time, depend- 
ing on their effect and the way in which the patient progresses ; 
but in beginning them, it must be remembered that they are 
apt to cause a patient to feel exhausted ; in fact, a patient is 
occasionally found not to be able to use them at all on this 
account. 

Depletion may be obtained with advantage in certain cases by 
direct bloodletting. A free scarification of the cervix will not 
infrequently, early in the acute cases, give an immense amount of 
relief, and may even materially limit the extent and severity of the 
attack. This aid in the treatment is much neglected at the present 
day, but it will at suitable periods in an attack of pelvic inflamma- 
tion be found of great service. If the treatment is attempted, it 
should be done in a thorough manner. The cervix uteri is to be 
well exposed by the aid of a speculum, and deeply punctured at 
a number of points, so as to cause free bleeding. Ten or fifteen 
punctures are none too many, and from three to six ounces of blood 
will not be too much to withdraw ; it will, in fact, be difiicult to 
obtain so much. It may be desirable to have the depletion con- 
tinue for some little time, and if a light glycerin tampon will not 
aid the actual flow of blood, it will withdraw a portion of the 
watery element from the surrounding tissues, and thus in a mild 
way add its aid toward a continued depletion. It is not advisable 
or necessary to use all these methods of depletion in every case of 
pelvic peritonitis : they are the best methods at our command, and 
must be used with judgment as the indications for them arise in 
particular cases. In the acute form of the disease, when there is 
considerable induration, it has been proposed that an aspirating 
needle be thrust into the mass through the vaginal vault and the 
serous exudates drawn away. It is claimed that the depletion thus 
obtained will end the attack in a very short time. The amount of 
good derived by this measure will not be commensurate with the 
risks of carrying infection on the needle, and thus causing sup- 
puration. 

Should the pain become so great as to be unbearable before the 
inflammation has subsided sufficiently to give relief, it is eminently 
proper to administer an opiate for its temporary action. It is well 
to remember that opium in any form depresses the heart, lessens 
the excretive and absorptive powers of the tissues, and inhibits 
peristaltic action of the bowels, all of which effects are contra- 



PELVIC INFLAMMATION. 491 

indicated in these diseases. It is exceedingly desirable that excre- 
tion and absorption should be free and that the bowels should remain 
soluble. For these reasons, if it becomes necessary to use an opiate 
— and it should only be used if absolutely necessary — that form 
is to be selected which will cause the least harm, and it is to be 
administered in as small quantities at as long intervals as is com- 
patible with obtaining the effect desired. Morphia, used hypo- 
dermically, is least objectionable of all the forms of opium. Fre- 
quently one dose of an eighth of a grain is sufficient, but it may be 
necessary to repeat it at intervals of five or six hours for several 
doses. One injection of morphia in this dose will often relieve the 
patient of her intense pain until a movement of the bowels can be 
secured, when, as a rule, there will be no necessity for its repetition. 
The one dose can do no possible harm ; it does not even delay secur- 
ing the desired movement of the bowels. 

Counter-irritants are not of any great importance in the acute 
form of the disease, but when it has assumed more of a subacute or 
chronic condition, they have their uses. Iodine applied freely to the 
vaginal vault and over the lower part of the abdomen once a day will 
give a certain amount of relief; whether it be actual or imaginary 
matters little ; it can do no possible harm, and at least gives the com- 
fort of the knowledge that something is being done. While not a great 
deal of reliance can be placed upon it, yet it is occasionally a matter 
of difficulty to explain the apparent cause and effect between the ap- 
plication of the treatment and the resulting relief. It is so uniformly 
used in conjunction with other treatment that it is sometimes hard 
to say whether or not it accomplishes good. Turpentine stupes and 
poultices to the abdomen do no harm and little good ; what good 
they do accomplish is incidentally through the heat which accom- 
panies their application, and is more mental than real : the good 
derived from blisters is hardly sufficient to counterbalance the 
amount of suffering they cause. These are all remedies which are 
very generally used, and serve as well as anything else to keep the 
patient satisfied that every possible thing is being done for her. 

Little or no attention need be paid to the pulse and temperature, 
other than to watch them closely in order to note the progress of the 
disease. They are symptoms which will take care of themselves, 
and never call for any especial treatment : they will fluctuate with 
the inflammation, but seldom rise sufficiently high, or remain high 
long enough, to cause any organic changes in the tissues, unless pus 



492 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

be present. Under any circumstances the disease is to be treated, 
and not its symptoms. Antipyretics are never indicated, and only 
when sepsis arises are heart-stimulants called for. Diuretics and 
diaphoretics would have their places for purposes of depletion were 
there not much more prompt and efficient means at our disposal. 
Diet and drink are both important elements in the treatment. The 
diet should be light, but nourishing — of such a character as to make 
as little fecal matter as possible, at the same time not to furnish an 
excess of fluid. It is well for the first few days of the attack that 
fluid should be withheld as much as possible, so that the inflamma- 
tory excretions may be the more quickly absorbed. 

The patient should be kept confined to bed until all pain and 
local tenderness have disappeared. If this line of treatment be 
carried out systematically and carefully, there is a chance in a cer- 
tain proportion of cases that a permanent cure may result and the 
parts be restored to a fair condition of functional health. Fre- 
quently, in spite of the most careful treatment, the result will only 
be a relative one, and although the inflammation may subside after 
weeks' or even several months' treatment, yet masses of the exuded 
lymph, together with the disorganized Fallopian tube, remain, and 
the inflammation may be relighted at any time, when the whole 
treatment will have to be gone through with again. In certain 
cases the inflammation never entirely subsides, but the woman is a 
constant sufferer from pelvic pain and discharges. She eats little, 
sleeps badly, and coitus is more or less painful, as is also walking or 
jolting of any kind. Such patients will apply for relief after years 
of constant suflering. An examination will disclose a condition of 
insterstitial salpingitis, masses of unabsorbed exudates, and a ten- 
der pelvis. The woman is able to be on her feet attending to her 
daily work, but is often a wreck of her former self. It is possible 
in many of these women to greatly improve their condition, pro- 
vided pus is not present in the pelvis. Their relief will naturally 
be only tentative, for as long as the exudates and diseased append- 
ages remain, they are liable under favorable circumstances to a return 
of all their aches and pains. The object to be aimed at in the treat- 
ment of these cases will be to bring about an absorption of the in- 
flammatory exudates and to accomplish a subsidence of the inflam- 
mation. In these women rest, especially sexual rest, is essential to 
success. The only sure way of accomplishing this is by separat- 
ing husband and wife, so that there may be no temptation : for this 



PELVIC INFLAMMATION. 493 

reason, where it is possible, a hospital is the best place to carry out 
the treatment. When this is not possible, tamponing is quite effect- 
ual — in fact, is the only safeguard. The patient must be guarded 
as much as possible from over-exercise, especially the use of sew- 
ing- and similar machines. The clothing must be warm and dry, 
and all unnecessary exposures to cold carefully avoided. The 
bowels should be kept soluble, and an occasional purgation for its 
depleting effect is indicated. Depletion may also be obtained by 
the use of the hot- water injections, as in the acute form of inflam- 
mation, but to result in any good it will be necessarv to use them 
systematically and for a long period of time : they should be used 
once or twice daily for months. Glycerin tampons, alternating 
with counter-irritation over the whole vaginal vault by painting 
with iodine, are of service if properly used. In fact, the tampon 
can be utilized, after the parts have been painted with iodine, with 
advantage. Dry tampons are frequently serviceable, even aside 
from their use in preventing coitus. The weight of a heavy and 
engorged uterus, retro-displaced, dragging upon tender and adhe- 
rent ovaries, together w^ith any movement of the pelvic organs 
caused by walking or riding, is a constant source of distress, pain, 
and backache. If the patient be placed in the knee-chest, or even 
the lateral position, and the whole pelvic mass of diseased and adhe- 
rent organs be allowed to gravitate toward the abdominal cavity, a 
tampon of some soft yielding material can be placed so as to fill the 
whole of the vagina, or even the posterior portion of it, care being 
taken not to pack it hard enough to cause trouble by its pressure. 
When the patient stands on her feet the pelvic organs gravitate 
back again toward their former position, but the tampon now re- 
ceives their weight and holds them somewhat above their former 
level, if only for a fraction of an inch — sufficient at least to take 
the drag off the adhesions. In a certain class of cases the relief 
obtained from this procedure is remarkable. It is essential that the 
tampon be of some soft, elastic, unabsorbable material, and that it 
be placed so as not to make too much pressure. Surgical cotton 
absorbs moisture, loses its elasticity in a few hours, and becomes a 
hard foreign body in the vagina. In addition, it shrinks, so that it 
loses its effect as far as giving support is concerned. Wool is the 
best material for this use. The tampon is much superior to a pes- 
sary for accomplishing this end. But the fict that a pessary at 
times gives relief to the patient suffering from pelvic inflammatory 



494 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

disease is only explainable in this way. In spite of the fact that 
a Smith-Hodge pessary will give relief in some few cases, it is a 
dangerous instrument to use in this disease. If an ovary is pro- 
lapsed, the pressure of the hard pessary will render its use unbear- 
able from the pain it causes. Should a fall or jar occur while the 
pessary is in situ, it might readily transmit so much of a blow as 
to light up a latent inflammation or to rupture a cystic tube or 
ovary. A tampon is preferable in every way, and it may be put 
down as a good and safe rule that a pessary should never be em- 
ployed in the presence of pelvic inflammation. Tampons, when 
used, should be removed at least every other day, and the vagina 
thoroughly cleansed and dried before a second one is introduced. 
If the tampon be thoroughly impregnated with some dry powder, 
such as boracic acid, it will keep sweet and' clean the longer. 

Where the application of iodine and glycerin has failed to relieve 
the pelvic pains and tenderness, ichthyol has proven itself a good 
substitute. Ichthyol, either in its pure state or mixed with glycerin 
in equal parts, and applied on a tampon to the vaginal vault, has 
succeeded in relieving the tenderness when everything else has 
failed. These applications in order to accomplish any good must 
be made at least twice a week for the course of several months or 
more. 

General medication accomplishes nothing directly ; although 
potash, mercury, and other remedies have been lauded for their 
specific effect, there is no drug which, given internally, will have 
the slightest effect upon the inflammation or its products. The 
absorption of the infiltrates and exudates will be greatly aided as 
the condition of health of the patient is good or bad, and every 
effort should be made to build up the general health to as nearly 
a normal condition as possible. General tonics and alteratives, 
combined with a proper regulation of the bodily functions, a well- 
ordered diet, limited but healthful exercise, and slight stimulation 
when indicated, is the proper course of general treatment to follow. 
It aids in the cure simply by placing the tissues of the body in 
a favorable condition for performing their work, and by giving 
Nature a chance to rid the parts of the inflammation and its 
products. 

Many of these patients are very much run down and have lost 
a considerable amount of flesh : they consequently need building 
up. Amongst other remedies for this purpose, electricity and 



PELVIC INFLAMMATION. 495 

massage have their place. General galvanism given daily for its 
tonic and stimulating effect, together with general massage, is 
indicated. It is not necessary to submit the patient, as a general 
thing, to a strict course of " rest treatment," as the good effects of 
this method may be obtained by a very material modification, and 
the woman may be up and about, attending to a moderate amount 
of work, sufficient to keep her body and mind occupied, without 
allowing herself to become over-fatigued. Electricity applied 
locally to the pelvis is of very indefinite value. In the acute 
attack of inflammation it has no place, and its use can only result 
in harm. When the force of the inflammation has subsided and 
it has settled itself down into a subacute or chronic condition, 
electricity may at times be used with advantage. It will occasion- 
ally relieve the symptoms of pain and uterine hemorrhage when 
other remedies have failed, and, on the other hand, it will often 
fail to give relief to these symptoms ; in fact, it will render them 
worse, when other remedies will bring about the desired effect. 
The relief obtained from this remedy is, like all others, merely 
temporary : it never cures the lesion : it simply relieves the symp- 
toms, and, the disease being still present, the symptoms are liable 
at any time, under favorable circumstances, to return. It is claimed 
for electricity by its votaries that large pelvic inflammatory masses 
will shrink and disappear under its use. Such is truly the case, 
but when we consider of what these masses are composed, it is easy 
to see why the remedy has been of service in causing them to dis- 
appear. They would have disappeared under any other proper 
method of treatment as well. In an acute attack of peritonitis great 
quantities of lymph are thrown about the diseased tubes and ovaries, 
forming large masses, which on palpation through the vaginal vault 
give an idea of size to the tube and ovary which is out of all pro- 
portion to their real size, the bulk of the tumor being made up of 
lymph-exudate. As the inflammation subsides. Nature causes an 
absorption of the lymph-exudate to a great extent, with the result 
that the pelvic mass gradually diminishes, until nothing but the 
adherent tube and ovary remain ; the appendage at times is quite 
small. In fact, the case under these circumstances has now as- 
sumed the chronic form of adherent interstitial salpingitis. It is 
this natural function of absorption which electricity stimulates and 
aids — nothing more, nothing less. In addition, the soothing effect 
of the galvanic current gives in a certain proportion of cases great 



496 ^iV^ AMERICAN TEXT-BOOK OF GYNECOLOGY. 

relief to the pain, while the uterine contraction induced by the 
stimulation of the uterine muscle, together with the direct effect of 
the cauterization upon the endometrium if sufficient current be ap- 
plied, gradually lessens the amount of blood lost. As an aid in the 
treatment of cases of subacute or chronic pelvic inflammation the 
procedure is valuable : it is to be regarded as an additional remedy, 
only one of many, to be used as simpler and easier forms of treat- 
ment fail or are slow of accomplishing their object. In using this 
remedy the galvanic negative current should be selected, and the 
application may be made either intra-uterine or intra- vaginal, the 
latter being the safer. Where it is desirable to aid Nature in 
absorbing exudates and relieving pain, the current should not be 
stronger than the patient is able to bear without much pain ; the 
application is to last but a short time, and is to be repeated two or 
three times a week. A good average application of the galvano- 
negative current, and one which is usually well borne, is in the 
neighborhood of fifty milliamperes applied for about three minutes. 
When the hemorrhage is excessive, it is better to use the positive 
pole, and the application should be made intra-uterine. Weaker 
currents, twenty to thirty milliamperes, are to be used where the 
galvano-positive current is selected, for the reason that this is much 
more painful than the galvano-negative and is not so readily borne 
by the patient. Even though the current is not sufficiently strong 
to cauterize the lining mucous membrane of the uterus, yet the posi- 
tive pole coagulates the albuminoids of the tissues and causes con- 
traction of the uterine muscles, in this way lessening uterine hem- 
orrhage, and cutting off the blood-supply. It is only by its judic- 
ious and careful employment that any good can be obtained from 
the use of electricity : the careless or ignorant use of it may read- 
ily do more harm than good. It is essentially a remedy the use 
of which will for the most p^rt remain in the hands of the special- 
ist ; it is of little use to the busy general practitioner, as the appa- 
ratus is complicated and expensive, and very considerable time and 
care must be spent in the application. 

Massage has a much more limited use in pelvic inflammatory 
lesions, and is more dangerous in unskilled hands. It requires no 
especial apparatus. In the acute stages of the disease it has no 
place whatever, but its greatest use is in the chronic form, where 
there is a considerable quantity of unabsorbed exudate and lymph. 
The manipulations of the masseur act as exercise to the parts and 



PELVIC INFLAMMATION. 497 

stimulate absorption. Under careful and very gentle movements 
it can readily be seen why in this way pelvic masses disappear or 
become smaller. Its use is decidedly objectionable even in this 
class of cases, for the reason that it is impossible to say whether 
or no there be pus in the midst of the mass. Many a Fallopian 
tube which is not much larger than normal contains pus or puru- 
lent material. The application of friction, pressure, or kneading in 
such a case may readily result in the leakage of some of the tubal 
contents into the abdominal cavity : even were there is no purulent 
matter present, the manipulation might very easily relight a sub- 
acute or chronic inflammation into an acute attack. It is claimed 
for the treatment that the pus from a pus-tube may be caused to 
escape into the uterine cavity and a cure thus be effected : it is 
much more likely that the pus would first escape through the fim- 
briated ends of the tubes or rupture take place in the walls of the 
abscess. In addition to the dangers attached to its use, its applica- 
tion is very painful unless the greatest care or the most delicate 
touch is employed. Even then some cases are for a long time 
intolerant of the necessary handling of the parts. The treatment 
is altogether too dangerous for the general practitioner to employ, 
and its use will always be confined to the hands of the few. Mas- 
sage in these diseases consists in kneading the pelvic masses and 
applying friction to them to cause their absorption, and in moving 
the uterus in different directions to stretch and free its adhesions. 
The manipulation is carried out with one hand pressing through 
the abdominal wall and one or two fingers of the second hand in 
the vagina. The vaginal fingers are used mostly for lifting up and 
fixing the uterus or pelvic masses ; the manipulations are carried 
on in great part by the abdominal hand. The reverse is true, 
however, in exceptional cases. 

When suppuration has accompanied an attack of pelvic inflam- 
mation, the treatment which has been detailed, and which is appli- 
cable to some cases of the disease in its non-suppurative and 
non-cystic forms, is not to be considered. In these cases all the 
symptoms of septicemia are added to those which accompany the 
inflammation, and frequently the patient's life is threatened, if not 
immediately, at least remotely and constantly. Should the pus be 
confined to the Fallopian tubes, Nature occasionally relieves the 
danger by allowing it to escape into the uterine cavity. It has 
been proposed to take the hint from Nature as to the method of 

32 



498 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



treating pus-tubes, and accordingly the treatment of aspirating 
the Fallopian tubes by passing an instrument into the uterus, and 
thence into the tube through its occluded uterine opening, has been 
advocated. Could the procedure be carried out with any degree of 
safety and certainty, it would offer a method of cure in a certain 
proportion of cases which would at times be satisfactory, and at the 
same time not be attended with the dangers of abdominal section. 
The objection to the treatment which should condemn it to oblivion 
is the uncertainty, nay almost impossibility, of passing the instru- 
ment. The catheter or probe, whichever it be, is of necessity small 
in diameter — so small that it would be just as liable to perforate the 
diseased and softened uterine wall as the occluded opening in the 
tube, even if the point which that opening occupied could be found : 

Fig. 307. 




Drainage of Pelvic Abscess from the Vagina, 

the manipulations necessary to accomplish the operation would be 
attended with so much traumatism and movement of the diseased 
parts that the inflammatory process might very readily be relighted 
or an abscess- cavity ruptured. If for no other reasons, the treatment 
should be utterly condemned ; but pelvic abscesses are so notori- 
ously multiple that the mere emptying of one of these pockets of pus 
would have no effect on those remaining, and there would be no 



PELVIC INFLAMMATION, 



499 



possible way of assuring one's self that some accumulation did not 
remain behind, it matters little how many had been drained. Where 
pus exists in the pelvis, there is but one treatment to be considered : 
evacuation by a surgical operation. A pelvic abscess should never 
be given an opportunity to evacuate itself There is a point of elec- 
tion for the opening which, if left to Nature, will rarely be chosen. 
When pus exists, it should be evacuated at once ; delay is unjusti- 
fiable, either for building up the patient or for any other reason. 
The patient will not improve as long as she is continuously absorb- 
ing septic matter, and the longer the delay the worse will be her 
condition for operation. If the abscess be an accumulation of pus 
within the pelvis independent of the Fallopian tube or ovary, be it 
either altogether intra-peritoneal or involving the cellular tissue, it 
is best to evacuate it without opening the general peritoneal cavity : 
the vagina is the one point at which this is feasible and proper. 
Even in those exceptional cases where the abscess has risen into 
the abdominal cavity, and it is possible to open it above the pubis 
without entering the general peritoneal cavity, the vagina offers the 

Fig. 308. 




Abscess-sacs opening into the Bowel. Opening obliquely above and below the level of the sac. 

better point of operation, as it gives just as good an opportunity for 
irrigation and a better one for drainage. This of course presup- 
poses that disease of the uterine appendages has been excluded — a 
diagnostic feat which is rarely accomplished. The opening should 
never be made in the rectum, as has been proposed, even though 
the abscess be pointing there. The abscess-cavity can neither be 



500 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

easily irrigated through the rectal opening nor can fecal matter be 
prevented from entering into it. Even where the opening occurs 
into the rectum spontaneously, it is slow to close, if it ever does so. 
Where the opening is higher than the sacs, it is practically impos- 
sible to prevent fecal matter from entering, in which case closure is 
hopeless. There is one almost insurmountable obstacle to this 
method of treating pelvic abscesses, barring exceptional cases. It 
is rare that one is able to say whether or not the ovary or Fallo- 
pian tube contains pus. Should they do so, a secondary abdominal 
section would become necessary, and it would then be complicated 
by the fistulous opening, which is always serious and which might 
prove fatal. As a matter of fact, the cases of pelvic abscess with- 
out ovarian or tubal suppuration are rare, and the inferences are all 
in favor of there being involvement of these organs, especially when 
the etiology of the disease is taken into consideration. In view of 
these facts, the proper treatment of pelvic abscess is almost inva- 
riably by abdominal section, under which circumstances the parts 
can be readily exj^lored, the exact pathological condition noted, 
and the appropriate treatment applied. The operation from above 
amounts to little more than opening an abscess, and the certainty of 
complete evacuation that it gives the operator and patient is a great 
desideratum. 

Where the pus is confined in the Fallopian tube or ovary, it has 
been recommended that vaginal puncture be practised for its evac- 
uation. This method of treatment is so faulty that it is best never 
to recommend it. Where vaginal puncture would probably be the 
better procedure for unskilled hands in a general pelvic abscess, 
especially one which required such immediate evacuation that a 
skilled operator could not be obtained, it is never justifiable in 
abscesses confined to the uterine appendages and the lymph imme- 
diately surrounding them. As has been already said, this variety of 
pelvic suppuration is rarely confined to one cavity, but consists of a 
number of small pockets, none of which communicate with the 
others. The Fallopian tube itself may* contain as many as three 
distinct and separate pockets; the ovary forms a cavity of its own, 
and two or more pockets are often found in the lymph in which 
the Fallopian tube and ovary are buried. The chances of more 
than a partial evacuation of the pus being obtained would be very 
scanty indeed. This objection has been recognized even by the 
advocates of this method of treatment, and for the purpose of 



PELVIC INFLAMMATION 



501 



overcoming the difficulty they have gone so far as to advise that 
the abdominal cavity be opened, the parts explored, the various ab- 
scesses located, and each punctured in turn from the vagina. If the 



Fig. 309. 




Stricture of the Fallopian Tube : the ovary enlarged by chronic ovaritis. 

abdominal cavity be opened, it would seem the height of folly not to 
complete the operation. But even with the abdomen opened it is at 

Fig. 310. 




Showing Multiple Abscess-cavities in a case of Pj^osalpinx, demonstrating the uselessness of the 

treatment by tapping and draining. 

times absolutely impossible to locate all the abscess-cavities before 
the parts are enucleated. Even in the few cases in which the pus 
could be thoroughly evacuated the broken-down abscess-sacs, cheesy 



502 AJV AMERICAN TEXT-BOOK OF GYNECOLOGY, 

Fallopian tubes and ovaries would remain beliind to cause the 
patient a long chronic invalidism, even should she ultimately re- 
cover. The best results which one could hope to obtain from this 
method of treatment would leave the patient in exactly the same 
condition as a woman who had suffered from a pelvic inflammation, 
and after its subsidence had been left in a condition of chronic in- 
terstitial salpingitis and ovaritis. She would ever after carry a dis- 
organized Fallopian tube and ovary, and would be liable to recur- 
ring attacks of pelvic inflammation, any one of which might result 
in suppuration or in death. Purulent salpingitis and ovaritis, unless 
they end in death in from a few days to a week, are chronic condi- 
tions, and give ample time to allow the physician to obtain com- 
petent assistance for performing an abdominal section. 

The treatment of those rare accumulations of pus within the pel- 
vis which are extraperitoneal, and which do not involve the uterine 
appendages, differs in no way, in' its first steps at least, from the 
treatment of the intraperitoneal abscesses. It is impossible to make 
a diagnosis of this condition prior to an abdominal section. When 
the abdomen is opened and the abscess- walls are found to be mov- 
able enough to be brought into the abdominal incision, it is best to 
aspirate, empty the sac thoroughly, irrigate the cavity with hot 
Aivater, stitch the opening in the sac to the abdominal incision, and 
place a drainage-tube into the cavity. • 

Should it be found that the sac could not be brought sufficiently 
high to be stitched into the abdominal wound, a vaginal incision 
should be made, the pus evacuated, and the drainage established 
from below. Until the abdomen has been opened and the diag- 
nosis established this treatment is manifestly improper. Should it 
be thought desirable after the diagnosis has been established, a 
second incision could be made above Poupart's ligament and the 
abscess-cavity reached by dissecting down into the cellular tissue 
below the reflexion of the peritoneum, pushing the peritoneum for- 
ward, as in operations on the bladder or for ligating the iliac ves- 
sel, and in this manner reaching the accumulations. The vaginal 
opening, however, where possible, is to be preferred. 

The ultimate treatment of pelvic inflammation is abdominal sec- 
tion in those patients who do not fully recover from the primary 
attack, and are left with their uterine appendages so diseased and 
disorganized that the symptoms produced by their presence either 
threaten life or so disable the woman as to incapacitate her for her 



PELVIC INFLAMMATION, 503 

daily vocation, and render her life a burden. It matters little 
whether pus be present or not, as many women suffer more from 
chronic interstitial salpingitis than they would from pyosalpinx 
or ovarian abscess. It would be well in the case of many patients, 
where there is no pus, to first try the medicinal treatment already 
described, but in this we are forced to make a distinction between 
the poorer and better-class patients. It has often been objected that 
no such distinction should be made, but it is well known that a given 
amount of involvement and destruction in a woman who can aflPord 
to undergo the time, trouble, and expense of a necessary course of 
treatment will give little or no permanent trouble, where a similar 
involvement in the case of a woman who is not able to afford the 
treatment will render her life miserable and will give rise to recur- 
rent attacks of peritonitis, each one increasing the local condition 
and endangering the life of the sufferer. Even were they both to 
suffer the same amount, the rich woman can afford to go to bed and 
become a semi-invalid, while the same thing to the poor woman often 
means starvation for herself and children, or the poorhouse. Though 
the operation be a dangerous one, the physician is justified under 
such circumstances to counsel a poor woman to take the risks, with 
the chances of regaining her health and putting herself in a condi- 
tion to bear the burden of life, where he would probably not think 
of advising the well-to-do patient to undertake the operation — not, 
at least, without a long and thorough trial of the medicinal — if it 
may be so called — treatment. If a patient's symptoms can be con- 
siderably ameliorated by treatment, she will often prefer to bear the 
lesser ills of her condition, than what to her are the greater ills of 
a surgical procedure. Unless a woman is subject to recurrent attacks 
of peritonitis, the disease may be left in situ without any danger to 
life, provided always that pus be not present : in these cases it is 
simply a matter of comfort or discomfort with a patient. Many of 
them suffer so much pain that they will accept an operation as soon 
as it is proposed to them, it matters little what the risk be, while in 
the case of others the idea of an operation is so horrible that they 
will rather bear any amount of suffering than even consider the 
radical procedure. The question of operation is one which must be 
left with the patient for decision after having fairly placed the facts 
before her. The dangers of an operation for pelvic inflammatory 
disease in the hands of trained gynecologists are not much greater 
than those which attend each severe recurring attack of peritonitis. 



504 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

It is not possible to say just what the death-rate amounts to, but an 
honest investigation would find it not much below 10 per cent, in 
the hands of the many. In the hands of a few it reaches a lower 
limit. The fact that the woman is having recurrent attacks of peri- 
tonitis is one of the strongest indications that an operation for the 
removal of the appendages is required. It is not possible to lay 
down any hard-and-fast rule by which one may be guided in 
deciding for or against an operation; each patient presents her 
own individual peculiarities, which must be taken into considera- 
tion. It can only be said that as long as the diseased appendages 
remain in the pelvis the woman is not cured : she is only relieved 
for the time, and at any moment a new attack of inflammation may 
be lighted up and the original condition be reproduced. 

The Operation. — Abdominal section is the only method of remov- 
ing the uterine appendages in pelvic inflammatory diseases, whatever 
may be said of their removal by other methods for other conditions. 
Their removal by the vaginal operation is extremely difficult and in 
many cases would be impossible. The operation is divided into two 
stages: the opening of the abdominal cavity, and the removal of the 
appendages. The preliminary step, opening the abdominal cavity, is 
common to all abdominal operations, and needs no particular enun- 
ciation here. There is no danger to be met with until the peritoneum 
is reached, and then only in case there is adhesion of the omentum 
or intestines. This fact can be readily determined by picking up the 
peritoneum between two pairs of hemostatic forceps, and rolling it 
between the fingers. The merest nick will allow the air to rush in, 
when if the intestines are not adherent they will drop back into the 
abdominal cavity. If either the omentum or the intestines are 
adherent to the parietal peritoneum, they are to be carefully sepa- 
rated by gradually inserting the finger between them. The omen- 
tum may be found adherent over the inlet of the pelvis and greatly 
thickened by inflammatory infiltrate. If such be the case, it must 
be gently freed with the fingers, care being taken not to tear the 
bladder or the adherent loops of intestines. It is usually easy to 
begin at the lower edge of the omentum to free it, working upward 
from the pelvis toward the umbilicus. When it is tightly adherent 
to the bladder and its lower border cannot be clearly defined, it is 
well at times to begin above and work down toward the pelvis. The 
finger should be passed high enough in the abdominal cavity to 
reach a point where the omentum is free ; then, with the finger 



PELVIC INFLAMMATION, 505 

between it and the intestine, it can be separated with more safety 
than from below : if when the bladder is reached there is any 
uncertainty as to where that organ ends and the omentum begins, as 
is at times the case, the apron can be ligated and separated at a safe 
distance above the doubtful point. 

If when the omentum is loosened it is found that it is suf- 
ficiently torn to cause free bleeding, the oozing points should be 
caught up with a pair of hemostatic forceps and ligated. Should 
there be a number of bleeding points, time will be saved if a liga- 
ture be thrown about the omentum above these and the included 
portion amputated. This is of especial importance and advantage 
if it is thickened by inflammatory deposits. After having disposed 
of the omentum, the intestines must next be dealt with. If they 
are unadherent, the finger passes down through them into the 
pelvis, locating first the uterus, and then the Fallopian tubes and 
ovaries. Should the intestines be found adherent, they must first 
be carefully but completely freed from all points of attachment. 
The adhesions may exist at but a few points, and be easily broken ; 
on the other hand, they may be most extensive, and so solid that 
separation can only be accomplished with great difficulty and dan- 
ger of rupturing the bowel-walls. Every loop of intestine which 
overhangs the pelvis, even the vermiform appendix, has been found 
to be involved in the general mass. The separation of these, espe- 
cially if deep in the pelvis, is much facilitated by using the sight 
in addition to the touch. One of the great advantages of this is 
that the operator can be absolutely sure of what he is dealing with, 
and can see any commencing tear in the bowel-wall in time often to 
avoid a serious injury. The elevated hip — Trendelenberg — position 
allows the use of both touch and sight, and any surgeon who would 
willfully neglect the advantage to be derived from the combined use 
of these two senses does not do his whole duty to his patient. It is 
in this point of separating adherent intestines deep in the pelvis that 
the position gives its greatest advantage and becomes invaluable. 
The adhesions are freed by one finger being gently but firmly in- 
serted between the first knuckle of intestine which is adherent and 
the organ to which it is fast. A to-and-fro motion will often succeed 
in loosening it when a steady pressure at one point will accomplish 
nothing. If the adhesion is stubborn at one point, the finger glides 
to another and another, until it finds a weak point from which to 
begin : after the beginning is made the rest is comparatively easy. 



506 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

At times it will yield easily on top ; at others the first point of weak- 
ening will be found by passing the finger to the sides or even under 
the part. As each knuckle is freed it should be brought into the 
abdominal incision and carefully scrutinized. The points at which 
the adhesions existed will be found stripped of their peritoneum : if 
these points are small and not bleeding, they may be ignored ; if 
bleeding freely, a few superficial stitches of silk or catgut will bring 
the edges of the peritoneum together and stop all flow. Exposure 
to the air for a short while may in itself stop it. If the serous and 
muscular coats are both torn through, stitches should be placed so 
as to turn the doubtful point into the bowel, and any possible danger 
of future perforation at these points will be obviated. When the 
intestines are all freed and properly treated, they, together with the 
omentum, are crowded back toward the diaphragm and a large 
sponge placed in the abdomen, so as to keep them out of the pelvis 
while the operation is completed : the sponge does the additional 
duty of absorbing any blood or septic material which may flow 
toward the abdominal cavity during the course of the subsequent 
manipulations. Should the bladder have become injured, it should 
be repaired before proceeding further. Each and every step of the 
operation is to be fully completed before proceeding to the next, so 
that no point in the technique may be forgotten in the final steps 
of the operation, or complications will arise to embarrass the subse- 
quent steps. It is well to locate and note the condition of both ap- 
pendages before beginning their enucleation, and usually it is best 
to free both of them and the uterus before beginning to place the 
ligatures. If this be done, the parts can be brought more fully and 
easily into the abdominal incision, and there will be less likelihood 
of the first ligature becoming loosened while adherent parts are 
being separated on the opposite side. In the enucleation the finger 
glides about over the parts until it finds a weak point or a point at 
which it can be passed down deeply into the pelvis. It is essential 
that this should be posterior to the broad ligament, between it and 
the sacrum. The Fallopian tubes and the ovaries are situated on 
the posterior surface of the broad ligament, and the adhesions will 
almost always be found at this point. The finger should glide 
between the appendage and the sacrum. It is well where possible 
to follow the curve of the sacrum, keeping the palmar surface of the 
finger — or fingers if two be used — toward the pubis, sweeping the 
finger from one side of the pelvis to the other and in this manner 



PELVIC INFLAMMATION, 507 

freeing all adhesions to this bone. This will allow the fingers to 
pass under the ovaries, tubes, and uterus if it be retrodisplaced, and 
they can be stripped loose and lifted out of the pelvis with com- 
parative ease. The aim should be to get the finger to the lowest 
point in the pelvis and work upward, and not from above downward. 
However, at times one is forced to work first at one point, and then 
abandon it and go to another and another, coming back finally to 
the original one. It is only by educating the fingers to the work 
that it can be performed accurately. In making the enucleation 
care should be taken to do as little damage as possible to the broad 
ligament, as it bleeds freely wherever injured. It may be necessary 
at times to ligate the one side before enucleating the opposite one, on 
account of the bleeding. If this should be the case, care must be 
taken not to loosen the ligature while completing the work. As 
soon as the appendages and uterus are freed the ligatures are to be 
placed and the diseased parts removed. The Fallopian tube and 
ovary are caught firmly in one hand and drawn well through the 
abdominal incision, while the other hand passes the pedicle staff 
containing the ligature through the broad ligament, it being well to 
pass it below the loop of the round ligament, which will be readily 
observed on the anterior aspect of the tense broad ligament. If 
this be done and care be taken not to cut the loop of the round 
ligament when the Fallopian tube and ovary are removed, there 
will be less danger of the ligature slipping from the stump. As 
soon as the ligature staff has perforated the broad ligament the 
staff is withdrawn and the silk left in situ as a double ligature; 
the double end is then cut, and hangs as two separate threads 
perforating the broad ligament. The two strands of silk are so 
twisted that when their respective ends are tied, one around each 
half of the mass, they form a figure-of-eight, each half compressing 
one-half of the pedicle, and the two halves being drawn closely 
to each other. While placing the ligature the broad ligament should 
be held well up into the wound, but as the knots are tied tightly, 
the assistant who is holding the mass should relax his hold 
and allow the broad ligament to retract, else when the mass is 
cut away there will be a strong tendency on the part of the 
broad ligament to pull down through the ligature, thus causing 
hemorrhage. Care is to be taken that the Fallopian tube is 
included in the ligature up to the uterine cornua. In some cases 
it is necessary to include uterine tissue in order to get a pedicle 



608 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



healthy enough to hold the ligature without cutting through. Fre- 
quently the ligature cuts through the pedicle like a knife, com- 
pletely amputating it. It becomes necessary then to pass a ligature, 
by means of a curved needle, deep into uterine tissues at the cornua 
in order to control the bleeding. The same proceeding may become 



Fig. 311. 




Ligation by Figure-of-eight Ligature of the Fallopian Tube and Ovary. 

necessary on the side of the pelvic wall. It is a serious question 
whether in such cases the proper treatment is not found in the com- 
plete removal of the uterus, together with the appendages. Patients 
with such lesions, when the appendages alone have been removed, 
are very prone to return for treatment, suffering with leucorrheal 
discharge, pain, and continued bleeding : the uterus in such cases is 
often found to be still enlarged, and the writer has on several occa- 
sions been compelled to remove it in order to secure a cure. 

The Staffordshire knot, or the so-called Tait knot, is an exceed- 
ingly dangerous one, and should be avoided, especially by beginners. 
The knot is so complicated that it is difficult to tie, and should any 



PELVIC INFLAMMATION. 509 

one part of it be inaccurately and lightly applied, the whole loop is 
liable to become loose. Occasionally the pedicle is so large that it 
is not safe to include it all in one ligature. It is then best to tie in 
sections, quilting it from side to side as the cobbler does in his work. 
When the ligature has been firmly secured, the Fallopian tube and 
ovary are cut away, leaving sufiicient of a button to ensure that the 
ligature will not slip off. After cutting away the appendage the 
stump should be seared with a Paquelin cautery as an antiseptic 
precaution. There is always a small portion of the lining mem- 
brane of the tube protruding from the centre of the stump often 
containing septic matter, which it is much safer to destroy than 
to leave free in the torn and denuded pelvis. When the ligatures 
are tightened, usually all free hemorrhage ceases and the only 
bleeding is merely an oozing, which will stop of its own accord in 
a short while. It may be advisable to place a ligature about some 
point which bleeds with especial freedom, but usually one or two 
of these at most are all that will be required. The points which 
will be most persistent and troublesome are those on the uterine 
surface. Wherever they are, if they are picjked up with a pair of 
hemostatic forceps, and a ligature carried under them with a curved 
needle, they can be readily controlled. There should be no hemor- 
rhage during the enucleation which is alarming, and generally it 
is better to ignore entirely what there is and finish freeing the adhe- 
sions with the certainty that the bleeding will end as soon as the 
ligatures are secured about the pedicles. Should the bleeding be- 
come alarming, it is because the ovarian artery has been severed, 
and it is best to secure the vessel by passing a ligature around 
it. If a needle be passed through the broad ligament near the 
pelvic wall and the ligature secured, and another one through 
the broad ligament near the uterus and secured, the vessel will be 
caught at both ends. The enucleation may then be finished and 
the mass tied away in the usual manner. There is neither necessity 
nor occasion for packing the pelvis with gauze or sponges to control 
hemorrhage during the course of the enucleation : such a procedure 
is not needed in the case of venous bleeding, and can only delay 
and impede the operation, while in arterial bleeding it will only 
control the hemorrhage as long as the pressure is kept up. The 
bleeding vessel must be ligated as soon as the gauze is withdrawn, 
and the result of its use is simply the loss of valuable time. 
If during the course of the enucleation the Fallopian tube or 



610 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

ovary, or both, be found distended witb fluid, either purulent or 
otherwise, it may be well to empty them with the aspirator, so as to 
avoid their rupture during the operation, and consequent soiling of 
the torn and bleeding parts with septic matter. If possible, how- 
ever, it is better to remove the tumor without emptying it, as an 
enlarged ovary or Fallopian tube is easier to handle and enucleate 
than a small or collapsed one : care should be observed, however, 
not to rupture it. Should it rupture and the parts become bathed 
with the contents, or should one or more pus-pockets be found in 
the lymph surrounding the appendages and evacuated into the gen- 
eral pelvic cavity, the parts must be tlioroughly washed out and all 
traces of the fluid removed. If the intestines and omentum have 
become soiled, they must also be carefully washed. For this pur- 
pose a long-nozzled irrigator is carried to the bottom of the pelvis, 
and several gallons of hot water are passed through it. To carry 
out this procedure two fingers of the one hand are placed in the 
upper angle of the abdominal incision to hold the intestines back 
toward the abdominal cavity ; the nozzle of the irrigator is then 
pressed toward the lower angle of the incision ; a funnel is thus 
formed through which the water from the bottom of the pelvis 
gushes freely, bringing with it all the pus, blood, and other debris 
which has been left there. The heat of the water acts in addition 
as a good hemostatic to the oozing points, and tends also to combat 
any threatened shock. While the irrigation is being carried out 
the fingers should play freely among the intestines, washing them 
thoroughly. Before closing the abdominal wound a last look 
at the stump should be taken in order that any tendency to slip- 
ping or loosening of the ligatures may be noted and corrected. 
Should there be any doubt about their perfect safety, a ligature 
can readily be thrown around the ovarian artery on each side of 
the stump with the aid of a curved needle, thus rendering assur- 
ance doubly sure. It is seldom during the course of an operation 
of this kind that the ureters are injured : such accidents have hap- 
pened, however, and this possibility must always be borne in mind. 
When large surfaces of peritoneum have been denuded and there 
is free oozing, when septic matter has soiled the seat of the opera- 
tion, or where a bowel has been badly damaged, drainage is always 
indicated. Drainage is probably more often required in this class 
of operations than in any other in abdominal surgery. A drainage- 
tube of glass or gauze is passed to the most dependent point in the 



PELVIC INFLAMMATION. 



611 



pelvis and brought out through the lower angle of the abdominal 
incision. The incision is closed, preferably with a silkworm-gut 
suture, although the character of the suture is immaterial, pro- 
vided it is surgically clean. 

Frequently during the course of an operation the question arises 
whether or not certain parts should be removed. If it be necessary 
to remove the Fallopian tube on one side, its accompanying ovary 
had better go with it, and vice versa. Either Fallopian tube or 
ovary by itself is useless, and both are possible sources of future 

Fig. 312. 




stump after removal of Uterine Appendages, showing double ligation of Ovarian Artery. 

danger. Should the appendages on one side be healthy, it is unwise 
to remove them together with the diseased ones on the opposite side, 
for the reason that it renders the woman sterile and brings on the 
menopause with all its attending nervous phenomena. In spite of 
the fact that some good surgeons contend for the removal of both 
ovaries, it is better that the patient take the risk of a second opera- 
tion for the removal of the remaining one if in the future it become 
diseased. If the Fallopian tube is not already diseased, there is no 
good reason that it will become so if after recovery from the abdom- 
inal section the linino; membrane of the uterus be treated and the 



512 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

endometritis cured. It becomes necessary, in any event, to adopt 
this course in many cases after the appendages have been removed, 
in order to secure a complete recovery. The disease originated in 
the uterus, and the fact that it has spread to the Fallopian tube and 
the pelvic peritoneum is no reason why it does not still exist intra- 
uterine. As a matter of fact, many of these patients are not cured 
until the womb has been curetted and treated by alterative and 
stimulating applications. 

The question often arises as to whether an operation should be 
performed in the presence of an acute peritonitis. If one have the 
choice, it were possibly best to operate in the quiescent state ; but 
if any indications for a speedy operation exist, no hesitation need 
be had on account of the inflammatory attack ; its cure will be 
assured on the removal of the appendages. The large masses of 
plastic lymph which accompany it are broken down and disappear 
in the course of the enucleation : within twenty-four hours the 
pulse and temperature, which were high at the time of the opera- 
tion, approach the normal, and the patient convalesces within forty- 
eight hours. Neither need menstruation be a bar to operation. 
When both appendages have been removed, there is always a 
spurious menstrual flow within two days after the operation. The 
only possible disadvantage would be that the operation might be 
slightly more bloody on account of the pelvic congestion — not, how- 
ever, more than if an acute inflammatory attack were in progress. 

Where both appendages have been removed, the menopause 
usually becomes established. There are, however, frequent ex- 
ceptions to this rule, and patients return to the surgeon com- 
plaining that they are bleeding at regular intervals, and just as 
profusely as before. The cause for this has not been satisfactorily 
explained as yet. The explanation has been advanced that a small 
ganglion of nerves existed at the angle formed by the junction of 
the Fallopian tube and the uterus, and that there had been a failure 
to include and remove this ganglion with the appendage. Practical 
experience has long since proved the falsity of this theory. It has 
again been contended that an ovary — a third one — was left behind, 
but this has also been pro.ved to be untrue : these cases of continued 
bleeding are quite frequent, while but few men have ever seen the 
mythical third ovary, in spite of the fact that an eminent German 
authority states in his book that it is possessed by about every tenth 
or twelfth woman. Some few of these patients are relieved of the 



PELVIC INFLAMMATION, 513 

flow by a thorough curetting of the endometrium : in others this 
procedure has no effect. Usually, after a shorter or longer interval, 
menstruation, which at first remained fairly regular, becomes scanty, 
and finally disappears, the cause for its continuance remaining a 
mystery. 

The relief following the removal of the uterine appendages is 
not always the same, nor is the best result obtained immediately. 
If it is only necessary to remove one side, the menstrual function 
continues much the same as usual, and many of the benefits of the 
operation are realized at once. Of course the aches and pains, 
which occur more from habit than from any real lesion, continue to 
a certain extent until the patient returns to a good condition of gen- 
eral health. This requires time and building up. Should both 
sides have been removed, all the nerve-symptoms of the meno- 
pause appear within a few weeks after the operation, and the 
woman oftentimes feels worse than before the operation was per- 
formed. The menopause, which is artificial under these circum- 
stances, assumes a shorter and more stormy course than when 
the woman changes naturally. The best effects of the operation 
cannot be expected until this time is past, which may not be for a 
year or two. The immediate relief from pain, however, is marked, 
and, although the woman is not altogether well, she is relatively 
and comparatively so : where she was a chronic invalid before, 
she is now able to be about and attend to her daily duties. The 
great trouble with surgeons is that they expect too much from the 
operation, and lead their patients to do the same. This is a great 
mistake. So much local damage has been done by the inflamma- 
tion, and the general health is so wrecked, that the woman will 
never again be the same well woman she once was : such a result 
is neither to be expected nor obtained in very many instances. 
An absolute cure should never be promised ; only relative results 
can safely be counted upon. 

The pain which so often remains with the patient after the ope- 
ration cannot always be accounted for. At times the omentum 
or intestine may become adherent to some denuded spot or to the 
stump. The dragging, incident to the peristaltic action would then 
give rise to pain. Frequently it is due to intestinal colic or to the 
compression of the nerve-filaments by the ligature. In some cases 
it is impossible to account for the pain on any other ground than 
that it was not originally caused by the ovarian or tubal disease, but 

33 



514 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

resulted essentially from a nerve-disease from the first. An opera- 
tion for the removal of the uterine appendages for pain as the only 
indication is rarely justifiable. Whether or not there has been a 
pelvic inflammation, the surgeon should always be able to demon- 
strate positive disease of the Fallopian tubes and ovaries by a 
bimanual examination before counseling a surgical operation for 
their removal. The pain may be the result of a pelvic inflam- 
mation, but it does not follow that the removal of the appendages 
will cure this symptom, unless the appendages are diseased and can 
be shown to be the seat of the suffering. 

Some of the worst and most hopeless cases of pelvic inflamma- 
tion recover after an operation. This is particularly so in pus cases. 
It is surprising to note how quickly they rally even when they have 
appeared to be most desperate. For this reason no woman should be 
refused the chance of recovery because she may seem too far gone 
for relief: unless she be actually dying there is hope, and a con- 
scientious surgeon should ofler her the last chance, forlorn as it may 
seem. The operation often means little more than the opening of 
an abscess, but, whatever it amounts to, a short etherization and a 
short operation frequently makes the difference between life and 
death with a patient : what is done should be performed as quickly 
as is compatible with safety, and the patient gotten back into bed. 
Should the enucleation give promise of being a long or hard one, 
and the patient aj^parently unable to stand it, it wxre better to 
empty out the pus and place a drainage-tube, leaving the com- 
pletion of the operation to some future time when the woman is 
better able to sustain the shock of the necessary manipulations. 

From time to time different substitutes have been sought for the 
removal of the appendages in pelvic inflammation. It has been 
proposed to open the abdomen, break up all the adhesions, and 
allow the parts to remain in situ. Again, it has been stated that 
it was proper to free the adhesions of a Fallopian tube containing 
pus, and squeeze the pus into the uterus by stripping the tube with 
the fingers. The fimbriated end of the tube being cut aAvay and its 
cavity washed out, the cut end is then stitched into the abdominal 
opening or the mucous and serous membranes brought together over 
the denuded portion. All manner of such procedures have been 
practised in the name of conservatism, each and every one of them 
being, in fact, more tedious and more dangerous than the complete 
removal of the diseased and destroyed appendages. The only justi- 



PELVIC INFLAMMATION. 



515 



fication of such surgery would be subsequent pregnancy. As yet 
there is little reported which is encouraging from that standpoint. 
To open the end of the Fallopian tube, which Nature has sealed to 
prevent the further escape of infectious matter, is only to invite 
the infection of the whole pelvic, if not abdominal, cavity. Fortu- 
nately, Nature again seals the opening with plastic lymph within a 
few hours after it has been returned to the abdomen, and the whole 
procedure has been nullified as far as the results expected are con- 
cerned. Such surgery is useless in this class of diseases, and can 
only end in disappointed hopes. The moment the parts are returned 
to their position in the pelvis they re-adhere. 

Is there, then, no hope of a cure for these women short of the 
removal of the appendages ? If they are able to bear their suffer- 
ings until the change of life is established. Nature will effect a cure. 
Pelvic inflammatory disease is essentially an affection of youth and 
middle age ; it seldom occurs in virgins or after the change of life. 
After the menopause it gradually becomes inactive, and finally ceases 
to give rise to any symptoms. As to whether or not a patient be 



Fig. 313. 




Pyosalpinx from a Woman over Sixty Years of Age. 

advised to wait for this natural cure will depend much upon her 
suffering, the length of time she has to wait, the condition of her 
general health, and her station in life. A well-to-do woman could 
readily tide over a few years more or less with comparative comfort 
and safety, while her less fortunate poor sister would be forced to 
call upon the surgeon for relief. 



516 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The changes which take place in a woman following the removal 
of both uterine appendages are the same as follow the natural change 
of life — none other, none less. The woman is sterile; she was 
sterile at the time of the operation, and would never have been 
anything else. Often the sexual appetite is increased ; never 
diminished, as is commonly supposed. The increase is simply 
the return of the woman's natural condition. Her pain and suf- 
fering and ill-health had inhibited the sexual appetite ; these being 
removed, the appetite returns in full force. Gradually over the 
course of years the appetite fades in exactly the same manner as it 
does following the natural menopause. In some women it is lost in 
a few years, in others not for many. The woman takes on a growth 
of flesh and becomes more matronly ; otherwise there is no change 
— no coarseness, no growth of hair on the face, no harshness of the 
voice, no masculine appearance. 

As a result of neglected pelvic suppuration, pus frequently 
finds its way to the surface and discharges ; oftener the patient dies 
of exhaustion and septicemia before this result is attained. Fistu- 
lous openings may appear in the rectum, the small intestines, the 
vagina, the bladder, the perineum, the abdominal walls, and the 
gluteal region. If the abscess has been unattended with involve- 
ment of the uterine appendages, sinuses will probably close and all 
signs of suppuration cease. If, on the other hand, the appendages 
are involved in the suppurative process, as they most frequently are, 
the sinuses will remain open in spite of all that may be done by way 
of medical treatment ; the discharges continue, and the patient grad- 
ually becomes more and more exhausted and emaciated, until she 
finally becomes bed-ridden, and dies after a long period of suffer- 
ing and misery. The treatment of such cases is unpromising. 
Abdominal section with removal of the abscess-sac is the only 
alternative, however bad the case may be. When the pelvis has 
been cleansed of the diseased appendages which form the focus of 
suppuration, there is of course a sinus opening into the pelvic cavity. 
This is a source of great and threatening danger to the woman for 
the first twenty-four or forty-eight hours after operation, but it is a 
risk which she must necessarily assume : there is no avoiding it. 
The sinus should be well irrigated from within the pelvis outward 
in whatever direction it runs, and it should be disinfected as 
thoroughly as possible throughout its whole course. If it passes 
through any considerable amount of tissue, it is well to introduce a 



PELVIC INFLAMMATION. 517 

drainage-tube into its outer end, so as to ensure the flow of suppura- 
tive material away from the pelvic cavity. The mouth of the sinus 
in the pelvis is to be thoroughly scraped, cleansed and closed by 
a few catgut stitches. Nature will in a few hours add additional 
barriers to any infection entering the pelvis by sealing the opening 
with plastic lymph. Should the opening be into the bladder or 
bowel, the edges of the perforation are to be carefully prepared and 
closed with stitches. It is possible that the condition of the bowels 
will be so bad that in the case of the small intestine a portion must 
be resected. When the opening is too low down in the rectum for 
closure, a drainage-tube must always be placed at the point of open- 
ing, and the bowels kept perfectly quiet with opium for three or 
four days, so that no fecal matter may escape before the opening is 
sufficiently closed by lymph. It is possible in a goodly number of 
these extreme cases to get a good result, and when the patients 
do pass through the operation safely, it is surprising to see how 
quickly they regain their health up to a certain safe point. At 
times they are so badly wrecked that perfect recovery is a matter 
of years. The adhesions are so extensive and dense, the patient in 
such a low physical condition, and the damage to viscera so irre- 
parable in many cases, that they are unable to stand the necessarily 
prolonged operation or they succumb to septic peritonitis. This, 
however, should be no reason for staying the surgeon's hand as long 
as he can give a reasonable chance of cure to a respectable propor- 
tion of such cases. These cases invariably die if left alone, and 
each one cured is a life snatched from the grave. 

The sooner the general profession becomes thoroughly imbued 
with the vast importance of the whole subject of pelvic inflamma- 
tion, and acts intelligently upon the principles here laid down, the 
sooner will we have to face a less number of such terrible examples 
of neglect and ignorance. 



ECTOPIC GESTATION. 



Definition. — By the term " ectopic gestation '' is meant a preg- 
nancy situated outside the cavity of the uterus, and the title ectopic 
is preferred to that of extra-uterine, as including, also, pregnancy 
in the interstitial portion of the tube, which, while ectopic, is not 
outside of the uterus. 

Cornual pregnancy will not be included in this article. 

History. — We shall not enter into the history of the subject, 
save to say that Albucasis, in the middle of the eleventh century, 
described the first known case of ectopic gestation. For centuries 
it was considered one of the rarest of Nature's freaks, but since 
March 3, 1883, when Lawson Tait of Birmingham, Eng., performed 
his first successful operation on a case of ruptured ectopic gestation, 
examples of this condition have been observed so frequently that 
the literature of reported cases is voluminous, and to Tait and his 
views of the etiology and treatment of pelvic hematocele is largely 
due our knowledge of the subject now before us. Instead of regard- 
ing the condition a rare one, we know now that it is comparatively 
frequent, and that every gynecologist in active operative practice 
must meet with several cases each year. Formad of Philadelphia, 
in a series of 3500 general autopsies, found 35 ectopic gestations. 

The relative frequency of this condition at the present time, as 
compared with the past, simply means that we are now better able 
to recognize such cases ; and many of the deaths formerly assigned 
to idiopathic peritonitis and to hematocele were undoubtedly due to 
ectopic gestation. 

Varieties. — For all practical purposes we may regard the tube 
as the primary seat of the ectopic gestation. When the fimbriated 
extremity of the tube is adherent to the surface of the ovary and 
embraces one or more Graafian follicles, we admit the possibility, 
after rupture of the follicle, of impregnation of the ovum before it 
leaves the follicle, and its development within the ovary, consti- 
tuting, in one sense, an ovarian pregnancy. Such an event, how- 



sis 



PLATE XXXI. 



B 




Combined Ectopic and Intra-uterine Gestation; operation five months after marriage: A, tube 
and ovary removed at operation; 1, gestation-sac containing amnion and giving chorionic villi under 
the microscope; 2, fimbriated extremity; 3, ovary; B, fetus contained within its membranes, passed 
fn)m the uterus on the day ft)llo\ving the operation. 



ECTOPIC GESTATION. 519 

ever, if it ever occurs, would be so extremely rare that it may be 
left out of consideration in a practical work like this and ectopic 
gestation be regarded as originally tubal. 

The idea that an " abdominal pregnancy '' ever occurs primarily, 
as such, has been abandoned. It seems neither rational nor possible, 
when we consider the absorptive power of the peritoneum, that an 
ovum should drop into the peritoneal cavity, meet with a spermato- 
zoon, and develop there. Knowing as we do how easily much 
larger and firmer masses are rapidly absorbed by the peritoneum, 
we do not believe that a young fertilized ovum would long escape 
destruction. We shall show later on how the condition called 
^' abdominal pregnancy '' originally started in the tube. 

Three varieties of tubal gestation are recognized, according to 
the situation : 

1. Tubal proper (free tubal) ; 

2. Tubo-ovarian ; 

3. Tubo-uterine or Interstitial. 

The first variety, that situated in the free portion of the tube, 
between the cornu of the uterus and the fimbriated extremity, 
includes by far the largest number of cases, and consequently is of 
the greatest importance. 

The tubo-ovarian variety we consider as still sub judice. As 
usually described, it includes the condition where the fimbriated 
extremity of the tube is adherent to the surface of the ovary, and 
the gestation takes place in the outer extremity of the tube, between 
it and the ovary. This variety is rare, and, as the treatment would 
be similar to that of the first variety, and the diagnosis would in all 
probability only be made at the operation or the autopsy, they wnll 
be considered together. We shall see later on that the direction of 
rupture may differ in the two cases. 

Careful observation of specimens of ectopic gestation removed 
by operation has largely modified the views held concerning the 
tubo-ovarian variety. In all probability cases have been reported 
as tubo-ovarian in which the ovary, just as coils of intestine or the 
uterus, simply formed a part of the sac created by adhesive perito- 
nitis binding together adjacent organs about the blood-effusion, re- 
sulting from rupture of any portion of the pregnant tube. 

In the tubo-uterine or interstitial variety the gestation occurs in 
that portion of the tube which is embraced by the uterine wall. 
This constitutes a distinct class, and will be considered separately. 



520 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

Etiology. — Concerning the etiology of ectopic gestation very- 
little is known. The theory which has gained the widest accept- 
ance is, that it is due to some lesion in the interior of the tube 
obstructing the ovum in its passage to the uterus. This lesion is 
in some cases a desquamation of the epithelium, in some, a stenosis 
of the lumen by the traction of peritonitic adhesions, causing an 
angulated condition of the tube, and in others, a change in the 
epithelium short of desquamation, but sufficient to cause a departure 
from its normal function. The theory of lesion in the interior of 
the tube seems to cover a large number of cases, and is strengthened 
by the fact that frequently a history of previous trouble on that side 
of the pelvis can be elicited, and the event is often, though not 
always, preceded by a period of sterility : it is also supported by 
the theory that the normal site of impregnation is in the uterus, 
and that if the ovum is delayed and impregnated in the tube, 
ectopic gestation results. 

In some cases of ectopic gestation, on the other hand, the micro- 
scope has disclosed in the epithelium no deviation from the normal. 

This disaster may occur at any age : it may happen in a woman 
who has borne several children, or it may occur in the first preg- 
nancy a few months after marriage. 

As stated above, the event is often preceded by a long period of 
sterility, and yet it may follow a confinement by only a few months ; 
in fact, it may accompany an intra-uterine pregancy. In this case 
the presence of the intra-uterine gestation may perhaps be the cause 
of the extra- uterine. 

Pathology. — We must consider — 

1. Changes which occur in the tube ; 

2. Changes which occur in the ovum. 

Following the lodgment of the ovum in the tube, the wall of the 
latter at first thickens ; this is chiefly due to its increase in vascu- 
larity, especially at the site of attachment. As the ovum grows the 
tubal wall becomes thinned and weakened by the ingrowths of the 
chorionic villi. Simultaneously with the growth of the ovum, the 
fimbriated extremity of the tube becomes progressively narrowed, 
until at about the eighth week it is completely occluded. The 
method of this occlusion has been accurately described by Bland 
Sutton. As the structures of the tube become swollen from the 
congestion, the peritoneal and muscular coats of the fimbriated ex- 
tremity form a prominent ring about the fimbriae ; this ring grad- 



ECTOPIC GESTATION. 



521 



ually projects beyond the fimbriae, then contracts and closes the 
ostium, leaving the fimbriae within the tube concealed from view. 
Now, until this occlusion occurs, either one of two events is 
possible : 

1. Rupture of the tubal wall ; 

2. Tubal abortion. 

After the occlusion of the fimbriated extremity the ovum can 
escape from the tube only by rupture of its wall. As the chorion 

Fig. 314. 




Gravid Fallopian Tube at the Tenth Week, showing complete occlusiou of the ostium : o, ovary with 

corpus luteum. 

develops, the tubal wall, thinned by distension and weakened by the 
inroads of the villi, finally yields, the exciting cause coming either 
from without or from within the tube. 

(a) From without : As a misstep, lifting, straining, or, not 
infrequently, from sexual intercourse, as was proven to be the case 
in the patient from whom the accompanying specimen was taken, 
where the rupture immediately followed that event. 

{b) From within : As a hemorrhage into the sac from separa- 
tion of the tubo-chorionic vessels in the process of organic growth. 

This rupture, when the gestation is situated in the tube proper, 
may take place in either of two directions : 

1. Through a portion of the tube covered by peritoneum — viz. 
into the peritoneal cavity. (See Fig. 315.) 

2. Through a portion of the tube not covered by peritoneum — viz. 
between the folds of the broad ligament — i. e. outside the peritoneal 
cavity. (See Fig. 316.) 



522 



AJ^ AMERICAN TEXT-BOOK OF GYNECOLOGY. 



In the tu bo-ovarian variety the direction of rupture would be 
into the peritoneal cavity only. 

When a rupture takes place into the peritoneal cavity, either 
one of two events may occur : 

(a) The hemorrhage may be sufficient to prove speedily fatal ; 

(b) The hemorrhage may be insufficient to prove speedily fatal. 
In the latter case the tubal laceration is small : the chorion in its 



Fig. 315. 



Fig. 316. 





Diagrammatic Section of Fallopian Tube, representing the two directions of rupture in tubal pregnancy: 
A, into the peritoneal cavity; B, between the folds of the broad ligament; h, wall of Fallopian tube; 
c, cavity of broad ligament. 



attempted escape plugs the opening and checks further hemorrhage ; 
the effiised blood then gravitates to the pouch of Douglas, finally 
coagulates, and is roofed in by peritonitic adhesions. In this way 
a new false sac is formed. As the chorion grows this new sac is 
ruptured, with a second hemorrhage, which in turn may be fatal, 
or may be again arrested and the fatal flow postponed. This 
process may be repeated several times, or, indeed, if the effiised 
blood is small in amount and the rupture occurs early, the effiised 
blood, fetus, and membranes may be absorbed and the patient 
recover. 

The death of the fetus usually occurs with the first hemorrhage, 
but Webster reports and minutely describes a case in which the 
fetus escaped into the peritoneal cavity and went to term, the so- 
called placenta remaining in the tube. This may have occurred 
either by a marked distension and thinning of the tube, allowing 
the gradual escape of the fetus through the tubal wall, with little or 



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ECTOPIC GESTATION. 523 

no hemorrhage, or the fetus may have gradually escaped through 
the fimbriated extremity — i. e. by tubal abortion. 

When the rupture occurs through the floor of the tube, between 
the folds of the broad ligament, the death of the fetus also usually 
occurs at once. 

Occasionally, however, the chorion only gradually changes its 
site of implantation, and the fetal circulation is maintained ; fetal 
life continues, and may go to full term with complete development 
of the child. 

Thanks to the frozen-section studies of Dr. Berry Hart, we now 
understand pretty clearly the changes which occur as the fetus 
develops. These changes were well exemplified in the case, the 
specimen of which is illustrated by the accompanying plate taken 
from a photograph. The folds of the broad ligament are opened 
out; the peritoneum is gradually lifted from the floor of the pelvis, 
from the lower portion of the rectum, and from the side, posterior 
surface, and fundus of the uterus. The uterus itself is enlarged, 
and usually pushed to the side opposite the gestation-sac. 

The distance the peritoneum may be lifted from the pelvis and 
its contents without its rupture, by the gradual development of the 
fetus or by repeated hemorrhages beneath it, seems almost incred- 
ible to one who has not actually seen it either at operation or 
autopsy. This elevation not infrequently reaches to the level of 
the umbilicus or above, and explains how an incision may be made 
into the gestation-sac, to one side of the median line, without going 
into the peritoneal cavity. We say, " to one side of the median 
line," for although the peritoneum may be stripped from the side, 
posterior surface, and fundus of the uterus, it seems to remain 
attached to the anterior surface, especially at its lower portion, and 
an incision in the median line would usually go through the peri- 
toneum. 

The distension of the broad ligament and the elevation of 
the peritoneum is well shown in Fig. 317. 

The amount of distension which the peritoneum forming the 
folds of the broad ligament will tolerate is sometimes exceeded, and 
a secondary rupture occurs into the peritoneal cavity, the primary 
rupture having taken place extraperitoneally — viz. from the tube 
down between the folds of the broad ligament; the secondary 
rupture from the broad ligament into the peritoneal cavity. Either 
one of two results may follow this event : 



524 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



1. Profuse hemorrhage into the peritoneal cavity, with or with- 
out the escape of fetus or fetus and placenta ; 

2. The gradual escape of the fetus into the peritoneal cavity, 
with little or no hemorrhage, the placenta retaining its attachment 
within the broad ligament and the fetus perhaps continuing its 
existence. 

The first result, profuse hemorrhage, is more likely to occur 
when the distension of the broad ligament is due to recurring hem- 

FiG. 317. 




Foetus. 



Levator ani. 



Transverse Section of the Pelvis of a Woman, with an Embryo and Placenta of the Fourth Month 
of Gestation occupying the Right Broad Ligament. 



orrhages, and will be referred to again as one of the possible indica- 
tions for operation in the treatment of an extraperitoneal rupture. 

The second result, escape of the fetus with continuance of its 
life, is of great interest anatomically, as it explains the majority of 
the cases in which a fetus has been found free among the intestines, 
and has given rise to the erroneous impression of primary abdom- 
inal pregnancy. 

We believe that by far the most usual place for the growth of an 
ectopic fetus escaped from the tube is between the folds of the broad 
ligament. Webster {Tubo-peritoneal Ectopic Gestation) has demon- 
strated the possibility of such a growth where the fetus gradually 
escaped from the tube directly into the peritoneal cavity and there 



ECTOPIC GESTATION. 



525 



developed. This, however, must be only a very rare exception to 
the rule that full-term ectopic fetuses are extraperitoneal. 

Tubal Abortion. — By this term is meant an expulsion of the 
ovum from the fimbriated extremity of the tube at any time before 
its occlusion. As this occlusion takes place before eight weeks, at 
the latest, tubal abortion is considered possible only during the first 
two months. This event is only likely to occur when the ovum is 
implanted in the outer third of the tube. Our knowledge of tubal 
abortion enables us to understand many cases of effusion of blood 
into the peritoneal cavity in which we find at operation or autopsy 
a tube empty, but with a collapsed appearance, as though it had 
been previously distended ; and the true nature of the case is often 
placed beyond doubt by finding among the blood-clots either a 



Fig. 318. 




Tubo-uterin( 1 rfc_n incy. 



fetus, fetal membranes, or a firmly-clotted mass, in the interior 
of which microscopical examination discloses chorionic villi. 

Tubo-uterine or Interstitial Pregnancy. — This variety of ectopic 
gestation includes those cases in which the impregnated ovum is 
lodged and develops in that portion of the tube which is embraced 
by the uterine wall. 



526 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 



In its life-history this condition differs from the other varieties 
of ectopic gestation in the following particulars : 
[a). Period of growth before rupture; 
(h). Direction of rupture. 

Situated as it is within the substance of the uterine wall, rupture 
of the sac would not be expected to occur at as early a period as in 
the varieties called tubal proper and tubo-ovarian, and this is borne 
out in the histories of reported cases. The wall of the gestation-sac, 
instead of rapidly thinning, as occurs when the ovum is lodged else- 
where in the tube, markedly thickens, resembling the uterine wall 
in normal pregnancy, and rupture frequently does not occur until 
the end of the fourth month. 

Direction of Rupture. — An interstitial pregnancy may rupture 
in either one of two directions : 1. Into the abdominal cavity. (See 
Fig. 319.) In this case the hemorrhage, without operative interfer- 
ence, is profuse and rapidly fatal on account of the thickness and 
vascularity of the w^all. 

Fig. 319. 




Diagrammatic Representation of Interstitial Tubal Pregnancy at the Time of Rupture. 



2. Into the cavity of the uterus. Such an event is considered 
possible, but, as it would be almost impossible to positively diag- 
nose the condition from normal intra-uterine pregnancy, this direc- 
tion of rupture we must regard as still sub judice. 

Cases of interstitial pregnancy are, as a rule, only diagnosed 
during life at operation necessitated by an intra-peritoneal hemor- 



Qj 




X 
X 
X 



ECTOPIC GESTATION. 



527 



rhage, the pregnancy up to the time of rupture being considered 
normal. 

Period of Tubal Rupture. — When the ectopic gestation is either 
of the tubal proper or tubo-ovarian variety, the rupture occurs 
some time between the third and the twelfth w^eek, most often near 
the eighth. In the interstitial variety rupture may occur at any 
time between the third and the twentieth week, most often in the 

Fig. 320. 




Pregnant Fallopian Tube laid open, showing the fetus killed by hemorrhage into its membranes, but 

without the escape of the fetus from the tube. 



fourth month. In tubal abortion, as previously stated, the ovum 
may escape from the tube at any time prior to the occlusion of the 
fimbriated extremity which occurs at the eighth week. 

The isthmus of the tube, that straight narrow portion just out- 
side the uterus, seems little adapted to distension with the growth of 
the ovum, and in our experience rupture of the gestation-sac has 



528 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



occurred at an earlier period here than when situated in the ampulla 
of the tube. In a general way, then, we might say that an early 
escape from the tube is more likely to mean rupture of a sac situ- 
ated in the isthmus, or a tubal abortion, than a rupture of the 
ampulla. 

Changes in the Ovum. — Notwithstanding the implantation of 
the ovum upon foreign soil, the fetal portions of the placenta are 
developed much as they would be in the cavity of the uterus ; it is 
only the maternal portion which is lacking, but this causes insecure 
attachment of the chorion, and, as the fetus develops, a rupture of 
some of the tubo-chorionic vessels easily occurs. This usually causes 
the death of the fetus, with or without its escape from the tube. 

So long as fetal life continues the growth and development of the 
ovum seem fairly normal. When death of the fetus occurs early, 
however, with hemorrhage into its membranes, a condition is formed 
so resembling a uterine mole that it has been called " tubal mole " 
or "apoplectic ovum." 



Fig. 321. 



CAVlTV 
OF 

AMNI 




Apoplectic Ovum, or Tubal Mole (natural size). 



The hemorrhage separates the ovum from the tubal wall, coagu- 
lates in the meshes of the chorion, causes contraction of the fetal 
sac by compression, and forms a mass resembling a dark-red blood- 
clot. This may be found in the tube, or, if the hemorrhage causes 
the death of tiie ovum at the same time it causes tubal rupture 
or abortion, the tubal mole may be found among a mass of blood- 
clots, either in the peritoneal cavity or between the folds of the 
broad ligament. This tubal mole may at first be mistaken for a 
simple blood-clot, but on section one can often find an amniotic 
cavity, as in Fig. 321, with or without a fetus ; or, if neither amnion 
nor fetus is discernible, a microscopic section will usually disclose 
chorionic villi. 



-d 



5* 




I — I 



ECTOPIC GESTATION. 529 

As previously stated, the death of the fetus usually occurs at the 
time of its expulsion from the tube. Rarely, however, fetal life 
continues, and may even reach full term. After its expulsion from 
the tube the following changes may take place in the ovum or 
fetus : 

1. When the death of the ovum occurs early, forming a tubal 
mole, this may be absorbed by the tissues in which it is lodged, be 
it peritoneum or connective tissue. Rarely suppuration in it may 
occur, perhaps from the proximity of the rectum. 

2. When death of the fetus occurs after it has reached a con- 
siderable degree of development and its bony framework is well 
formed, it may for a long time remain quiescent, the liquor amnii 
being gradually absorbed. Subsequently it may mummify from 
absorption of the fluids of the fecal tissues ; it may calcify, forming 
a lithopedion, may be changed into adipocere, or the soft parts 
may suppurate and the fetal debris be discharged into the rec- 
tum, vagina, bladder, or through the abdominal wall. 

Symptoms. — The symptoms of a patient afflicted with ectopic 
gestation are of great importance, for by these symptoms, coupled 
with a careful study of the history of the patient, the diagnosis is 
usually made. 

In almost every case there has been some departure from the 
normal menstruation. Usually the patient has gone over her 
monthly period for a longer or shorter time, it may be only a few 
days or may be several weeks. Occasionally, however, no period has 
been skipped, but there has been some change in the character of 
the last menstruation ; usually a lessening in amount. Not infre- 
quently, instead of the menstruation coming on in the usual way, 
there is at first only a splash, just enough to stain the clothes, then 
an irregular dribbling, followed by a more or less irregular, con- 
tinuous brownish discharge containing debris. The early symp- 
toms of pregnancy are often present, such as morning nausea, sensi- 
tive breasts, etc. The patient often believes herself pregnant, and 
this is of assistance in diagnosis. 

The next symptom which may surprise the patient is a sudden 
attack of very severe, sharp pain on one side of the abdomen : this 
pain is usually excruciating, causing the patient to feel faint, grow 
pale, and perhaps lose consciousness ; she is often covered with cold 
perspiration ; she not infrequently vomits ; the pulse becomes rapid 
and the temperature subnormal. Usually about this time the metror- 

34 



530 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

rhagia appears, and may continue several weeks, being due to the 
separation of the uterine decidua. As shreds are usually passed 
from the uterus, the patient often believes she has had a miscarriage 
and that her troubles will soon be at an end. Following this attack 
of pain, symptoms of pelvic peritonitis often present themselves. 
They may subside and the patient be up and around, when she is 
suddenly seized with another attack of sharp pain, syncope, etc., 
perhaps even worse than the preceding. 

Careful inquiry into the history of these cases often elicits the 
fact that the patients have been sterile for a longer or shorter 
period ; to this, however, there are many exceptions. To recapit- 
ulate, we would call attention to the following symptoms : 

(a) Amenorrhea; 

{b) Symptoms of pregnancy ; 

(c) Sudden sharp pain with syncope ; 

{d) Metrorrhagia ; 

{e) Often a history of previous sterility. 
Physical Signs. — If examined prior to rupture, one simply 
feels a distended tube, perhaps a little more boggy and vascular 
than a hydro- or pyosalpinx of a corresponding size. There is the 
same elongated, sausage-shaped mass, extending from the cornu of 
the uterus laterally or downward and backward, which one feels 
in a salpingitis. The uterus is enlarged ; the cervix is soft and 
patulous. 

If seen at the time of, or soon after, a primary intra-peritoneal 
rupture, the physical signs are often very meagre. There is usually 
no distinct tumor, and one can only get the sensation of fluid blood 
or an indistinct doughy feel in the pelvis 'and the constitutional 
symptoms of internal hemorrhage. 

When the rupture has occurred between the folds of the broad 
ligament, one gets all the physical signs of a pelvic hematoma. 

Let us now digress a little and consider the conditions pelvic 
hematocele and pelvic hematoma. By pelvic hematocele we mean an 
effusion of blood into the peritoneal cavity. This would naturally 
gravitate into the pouch of Douglas should this not be obliterated, 
or, if profuse, the blood may rarely flow over into the utero-vesical 
pouch as well. Coagulation, although longer delayed than in blood 
effused into connective tissue, finally occurs, and the blood-mass is 
roofed in by peritonitic exudate binding together adjacent struc- 
tures — coils of intestine, omentum, and uterus. 



ECTOPIC GESTATION, 531 

Etiology. — Concerning the etiology of pelvic hematocele our 
ideas have changed greatly within the past few years. While for- 
merly the text-books contained long lists of causes of this condition, 
operative experience has taught us that in nearly all cases we can 
assign but one cause — viz. ectopic gestation ; and, as the source of 
the blood, the tube, either from rupture or from tubal abortion. To 
this general rule we admit exceptions. We know that after the 
enucleation of diseased tubes and ovaries, or tumors of the same, 
an oozing surface is left which often gives rise to quite a large 
effusion of blood ; here, however, the cause is plain, and would not 
produce confusion. We also admit the possibility, from a slight 
traumatism, of rupture of peritonitic adhesions, some of which are 
markedly vascular, and would cause a considerable blood-effusion. 
Other possible causes are rupture of an ovarian hematoma or exces- 
sive hemorrhage from the rupture of a Graafian follicle. These 
events, however, would only rarely occur, and may be considered as 
exceptions to the general rule stated above. Most of the cases of 
regurgitation of blood from the tube we believe to be instances of 
tubal abortion. 

Physical Signs. — Previous to the encapsulation of the blood- 
effusion the physical signs are very few. There is a fulness in the 
pouch of Douglas which gives to the finger the impression of thick 
fluid, and from the floating up of the intestines there is usually more 
or less distension of the abdomen. When the effusion becomes 
encapsulated by peritonitic adhesions, the mass becomes firmer to 
the touch, the posterior fornix bulges, and the uterus is pushed 
forward. As the blood coagulates, the increase in the density of 
the effusion becomes apparent to the examining finger. The course 
and prognosis of pelvic hematocele are usually similar to ectopic ges- 
tation with intra-peritoneal rupture, and will be discussed later. 

By pelvic hematoma we mean an effusion of blood into the con- 
nective tissue beneath the peritoneum — viz. between the folds of the 
broad ligament. Here, again, although other causes are probably 
more common than in a pelvic hematocele, a very common cause is 
the rupture of an ectopic gestation-sac. The reason for considering 
other causes more frequent than in hematocele lies in the fact that 
varix of the broad ligament, due to various causes of venous con- 
gestion, is common, and where such is present but a slight trau- 
matism is required to produce a blood-effusion. 

Physical Signs. — These differ from those of a pelvic hematocele. 



632 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

While in the latter there is at first no limiting membrane, in the 
former the effusion is clearly limited by the folds of peritoneum 
forming the broad ligament, and a distinct tumor is developed. 
This tumor bulges down on one side of, and behind, the cervix, 
pushes the uterus forward and to the opposite side, and can be felt 
above Poupart's ligament when it has lifted the peritoneum from the 
pelvis. It seems to occupy all the space between the uterus and 
the sides of the pelvis, and if the finger is inserted into the rectum, 
the effusion, especially if situated on the left side, is found to have 
surrounded it, thus producing a stricture. This is due to the ring 
formed by the attachment of the peritoneum to the second portion 
of the rectum. 

Concerning the changes in a pelvic hematoma, two are possible : 

1. Absorption. This is possible even when the tumor is of quite 
a considerable size ; 

2. Suppuration. This seems frequently due to the proximity of 
the rectum, or if the hematoma is due to a ruptured tube, infection 
may come from the uterus through the stump of the lacerated tube. 
The suppurating hematoma may rupture into the rectum, vagina, 
bladder, or rarely above the pelvic brim. 

Diagnosis of Ectopic Gestation. — For a clearer discussion, 
this may be divided into two periods : 

1. Prior to tubal rupture or abortion ; 

2. Subsequent to tubal rupture or abortion. 

Few opportunities are presented for diagnosing ectopic gestation 
during the ante-rupture period. Unfortunately for the diagnosis, 
the patients during this period are apt to suffer but little. A large 
proportion of the cases have absolutely no symptoms leading them 
to suspect an abnormal condition. Occasionally, however, perhaps 
from surprise at the symptoms of pregnancy after a long period of 
sterility, or in their first pregnancy, in order to determine if that 
condition really exists, or from pain in one inguinal region, they 
present themselves to the physician, and under these circumstances 
the diagnosis has been made a number of times and its correctness 
verified by subsequent operation. 

To enable one to make a diagnosis of ectopic gestation prior to 
rupture we would emphasize two rules, which we consider of great 
importance : 

1. Whenever a pregnant woman presents herself with a mass at 



ECTOPIC GESTATION. 



533 



the side of or behind the uterus, always think of the possibility of 
ectopic gestation. 

2. Whenever any irregular symptoms of pregnancy occur the 
menstrual history should always be carefully inquired into, noting 
any change in its character, the exact duration in days, and its rela- 
tive amount during each of the months which are open to suspicion. 

The reason that so many more diagnoses of ectopic gestation are 
now made than formerly, and made correctly, lies in the fact that we 
are now on the watch for that condition. We need frequently to ask 
ourselves : Can this be ectopic gestation ? And this is especially 

Fig. 322. 




Deeidua expelled from the Uterus in a case of Ectopic Gestation : A, rotated, so as to show the shaggy 

uterine side; B shows the free surface. 

imperative when we meet with the early symptoms of pregnancy — 
nausea, sensitive breasts, softened cervix, etc., with a distended tube 
at the side of the uterus. This may be a hydro- or pyosalpinx 
simply coexisting with pregnancy. On the other hand, however, 
its boggy feel, a rather marked vascularity, and a careful observance 
of the second rule stated above concerning menstrual history may 
lead us to make a probable, if not a positive, diagnosis of ectopic 
gestation. 



534 ^iV^ AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Another factor in the diagnosis of this condition is the expulsion 
of the uterine decidua. While the ovum is developing in the tube 
there is forming in the uterus a decidua resembling that of a normal 
pregnancy, but differing from it in having a smooth, inner surface, 

Fig. 323. 




Decidua in Situ : fibroid uterus removed at time of operation for ruptured ectopic gestation. 

unbroken by the attachment of the ovum; in other words, having 
no decidua reflexa or serotina ; it is all decidua vera. This decidua, 
usually at or near the time of tubal rupture or abortion, is discharged 
from the uterus, sometimes entire, sometimes in small particles or 
shreds. It is a membrane varying from an eighth to a quarter of 
an inch in thickness, shaggy on the surface which is attached to the 
uterine wall, smooth, but presenting numerous fine wrinkles, on the 
inner free surface. On microscopical section it presents the appear- 
ance shown in the accompanying cut. When passed entire it forms 
a triangular sac, containing three openings, one corresponding to 
each Fallopian tube and one to the internal os. With the separa- 
tion and discharge of this decidua there occurs a metrorrhagia which 
may continue for several weeks. The passage of these shreds with 
the subsequent metrorrhagia is often a source of error both to the 
patient and her physician, and a miscarriage is a frequent erroneous 
diagnosis. 



ECTOPIC GESTATION. 



535 



There are two conditions from which the decidua from a case 
of ectopic gestation must be differentiated : 

1. The decidua of an intra-uterine pregnancy ; 

2. The membrane of a membranous dysmenorrhea. 

The decidua in an early miscarriage may resemble in places that 

Fig. 324. 




Photomicrograph of a Section of Decidua in a Case of Ectopic Gestation, showing the large decidual 

cells. 



of an ectopic gestation, but in the former there is found evidence 
of implantation of the chorion, villi, etc. which is wanting in 
the latter. 

The condition called membranous dysmenorrhea is surrounded 
with much confusion. It is perfectly possible, in the light of recent 
experience, that some of the cases described as membranous dysmen- 
orrhea were in reality cases of ectopic gestation. The points on 
which we would lay the greatest stress in differentiating the dys- 



536 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

meuorrhea from the ectopic gestation would be the frequent recur- 
rent character of the former at the time of a menstrual period and 
the absence of the symptoms of pregnancy. According to Wyder 
and Ayers, the dysmenorrhea! membrane does not contain the large 
cells seen in Fig. 324. 

The diagnosis of ectopic gestation has occasionally been made 
by curetting a uterus for supposed retained secundines, under the 
impression that the patient had had a miscarriage, and finding the 
uterus empty save for the decidua, which showed no chorionic villi. 

Diagnosis at the Time of, and Subsequent to, Tubal Rup- 
TUEE OR Abortion. — This is usually not difficult if a careful 
history is obtained, and this is considered in conjunction with the 
present condition of the patient. If seen at the time of tubal rup- 
ture or abortion, we find, coupled with the history of the patient dur- 
ing the ante-rupture period, the symptoms of sudden shock and 
internal hemorrhage. The patient is suddenly seized with a sharp, 
excruciating pain, usually on one side of the abdomen. She feels 
faint, grows pale, perhaps loses consciousness ; the surface of the 
body is often covered with cold perspiration ; the pulse is rapid 
and feeble ; the temperature is often subnormal. These symptoms, 
especially if there has been a period of amenorrhea, should always 
suggest a ruptured ectopic gestation-sac. If the patient survives 
this primary rupture — and she frequently does — the symptoms 
abate, only to be repeated at almost any instant, with or without 
a fatal result. 

If seen subsequent to the time of tubal rupture or abortion, we 
have, in addition to the history of early pregnancy, with one or 
more attacks of sharp pain and threatened collapse, the physical 
signs of either a pelvic hematocele or a pelvic hematoma, depend- 
ing on whether the rupture was intra- or extra-peritoneal. 

Differential Diagnosis. — The condition most likely to be con- 
fused with an ectopic gestation is probably a tube distended with 
either serum or pus, especially the latter. The physical signs 
of the two conditions prior to rupture often closely resemble one 
another, and, just as the rupture of an ectopic gestation-sac is fol- 
lowed by symptoms of shock and then peritonitis, so may the 
rupture or leakage of a pus-tube be followed by similar symptoms. 
The chief point in their differentiation is the difference in their 
clinical history. Here comes in the necessity for eliciting, if pres- 
ent, the symptoms of a possible early pregnancy. During the ante- 



ECTOPIC GESTATION. 537 

rupture period, as already stated, the greater vascularity and boggy 
feel of a pregnant tube may enable one to differentiate it from a 
pyosalpinx. 

Subsequent to the rupture the symptoms of the two conditions 
differ more widely : 

Ruptured Ectopic Gestation vs. Ruptured Pyosalpinx. 

Frequency of pulse greater. Frequency of pulse less. 

Temperature at first subnormal ; later rises Temperature rises steadily and markedly. 

slightly. 

Pain of shorter duration. Pain of longer duration. 

Patient shows loss of blood. Patient does not show loss of blood. 

Septic symptoms not usually present. Patient soon shows signs of sepsis. 

A fibro-myoma is sometimes confused wdth an ectopic gestation, 
and instances occur where the differential diagnosis is difficult. The 
means on which we rely are chiefly the difference in the history of 
the two cases : In the case of ectopic gestation the short history, 
first of amenorrhea, then attacks of sudden sharp pain, faintness, 
and metrorrhagia ; in the case of the fibro-myoma a long history of 
gradually increased menstruation, and perhaps gradually increased 
pressure-symptoms, without the symptoms of early pregnancy. 

In physical signs the fibro-myoma is usually much more inti- 
mately connected with the uterus and harder than the ectopic ges- 
tation. Both conditions may coexist, as in the case from which the 
specimen (Fig. 323) was taken. 

Into the differentiation between pelvic hematocele and pelvic 
hematoma due to ectopic gestation and those due to other causes, 
we shall not enter, believing our present knowledge insufficient for 
the task, and that most cases of pelvic hematocele and hematoma, 
especially the former, are due to the rupture of an ectopic gestation- 
sac. We believe, however, that in the present state of our know- 
ledge we should not declare to be due to an ectopic gestation an 
effusion of blood in the pelvis found at operation or autopsy, unless 
we find either a fetus or chorionic villi, or unless we have obtained 
from the uterus a decidua devoid of chorionic villi. 

The appearance of the chorionic villi, as seen in section under 
the high powers of a microscope, is well shown in Fig. 325. The 
central portion of the villus is seen to be composed of irregular- 
shaped cells, while the outer wall consists of a single or double 
row of cubical epithelium. Sometimes several villi may be seen in 
a single field, but not infrequently a large number of sections have 
to be cut and examined before a single villus can be found. 



638 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



The diiferences in the physical signs of pelvic hematocele and 
pelvic hematoma have already been given, and we will here only 
refer to them. 

Tumors of the ovary are sometimes confused with ectopic gesta- 
tion, but a careful study of the menstrual history and a search for 



Fig. 325. 




Photomicrograph of Chorionic Villi, found in the tube of a case of ectopic gestation. 

the physical signs of pregnancy will usually enable one to arrive at 
a correct diagnosis. Mistakes, however, in diagnosing ectopic gesta- 
tion are bound to occur, even with the most careful, from the fact 
that the condition is sometimes found at operation, when not a 
period has been missed and not a symptom of pregnancy has 
been presented. 

Treatment. — In considering this division of our subject we 
would recognize two periods, requiring separate discussion : 



ECTOPIC GESTATION, 539 

1. Prior to tubal rupture or abortion ; 

2. Subsequent to ruj)ture : 

(a) Intraperitoneal. 
{b) Extraperitoneal. 

When the diagnosis of an ectopic gestation is made prior to the 
rupture of the tube, the question which must present itself to every 
conscientious gynecologist is : How can we best subserve the interests 
of our patient? The advocates of electricity claim that by the cur- 
rent, either galvanic or faradic, the fetus is killed and the products 
of conception are absorbed. Admitting this as a possibility, we 
still believe that we are not consulting the best interests of our 
patient by so doing. 

In spite of the unfortunate case of Matthews Duncan, referred 
to in nearly every work on this subject, in which high currents, 
both galvanic and faradic, were used without killing the fetus, we 
believe that in the majority of cases, when seen early, electricity 
will kill the fetus, but that the danger to the patient disappears with 
the life of the fetus we cannot believe. Even after the death of the 
fetus^ hemorrhage into the tube sufficient to cause its rupture or 
tubal abortion, although it may not occur in every case, is still far 
from improbable. 

Further than this, while waiting for a cure by electricity or in 
the manipulation incident to its application, tubal rupture or abor- 
tion, with fatal hemorrhage, may occur before the surgeon has time 
to open the abdomen and remove the sac. A forcible illustration of 
this was the case illustrated by Fig. 323. The patient was moved 
from the bed to the table for the application of electricity. In so 
doing the tube ruptured, and before preparations could be made 
and the abdomen opened the patient was moribund from internal 
hemorrhage. 

Even if the fetus and membranes are absorbed under the use of 
electricity, a damaged tube is left, which is very likely to prove a 
source of future trouble. 

For these reasons w^e claim that electricity is not a satisfactory 
method of treating this condition. Galvano-puncture of the sac is 
dangerous, and ought never to be used. We believe that the method 
v^hich gives the best promise of deliverance, not only from present 
danger, but from future trouble, is coeliotomy, with removal of the 
pregnant tube. 

We admit the possibility of a tubal rupture or abortion with only 



540 



AN AMEBIC AN TEXT-BOOK OF GYNECOLOGY. 



a slight hemorrhage, the absorption of the effusion, and the recovery 
of the patient. This is a possibility, but no one can tell when this 
is to be the result, or when a rupture is to occur with hemorrhage so 
profuse as to be fatal within a few hours without operative interfer- 



FiG. 326. 




Tubal Rupture in Case of Ectopic Gestation. 

ence. From the time an impregnation occurs in a Fallopian tube 
until the tube is removed, that patient is never free from danger. 

Moreover, during the period prior to the rupture of the tube 
the operation for the removal of the gestation-sac is one of the 
simplest in abdominal surgery, and in the hands of a skilled 
operator should have a mortality nearly nil. 

Let us next consider the treatment at the time of, and subsequent 
to, tubal rupture or abortion. Here, again, we must consider two 
classes of cases depending on whether the rupture is intraperitoneal 
or extraperitoneal. If intraperitoneal rupture has occurred, most 



ECTOPIC GESTATION. 541 

electro-therapeutists agree that the time for their method of treat- 
ment has passed, and it is the consensus of opinion that there is 
now but one proper treatment — viz. coeliotomy and removal of the 
lacerated tubal sac. We do not mean to say that every case is fatal 
at its first hemorrhage. Many cases prove the contrary, and in the 
hands of careful observers it may be good practice, if the patient is 
improving in pulse, to wait till she has rallied from the shock of the 
initial hemorrhage before operating. The safest rule, however, is to 
prepare at once for operation. 

Just a word as to the method of procedure. Strict asepsis is a 
matter of great importance. The gestation-products and the effused 
blood at the time of or soon after rupture may be considered 
aseptic ; at the same time, they form a medium very easy to infect, 
and in an emergency operation, such as this in private practice often 
is, preparations in order to be rigidly carried out must be simple in 
detail. Fortunately, in heat we have an agent which will place our 
instruments and dressings above suspicion of infection. While 
arranging other details about the operation the instruments may 
be boiled in a soda solution (1 per cent, solution of washing 
soda), and at the same time water may be boiled for irrigation, if 
needed. In this way instruments may be prepared in about twenty 
minutes. 

During the preparation of the instruments the skin of the 
patient needs attention in order to avoid stitch-hole infection. 
Probably the best plan is to leave a towel soaked in a soft-soap 
solution on the abdomen, while the instruments are being sterilized. 
The abdomen is to be thoroughly scrubbed with soap and water, 
washed with alcohol, and then with bichloride (1 : 1000) before the 
initial incision. 

On making the incision in the median line down to the peri- 
toneum the latter is often found tense and dark, and at the first 
nick of the peritoneum fluid blood may well up in great abun- 
dance. No attention must now be paid to the blood already in the 
peritoneal cavity, but the source of the hemorrhage, the lacerated 
tubal sac, is to be seized at once, ligated and removed. The manip- 
ulations necessary for the removal are the same as those described 
in the article on Pelvic Inflammation. The same structures are 
dealt with, and, as a rule, the tubal pregnancy is complicated by 
adhesions, just as is the case in pus-tubes. We now have time to 
remove the blood-clots and products of conception, which are prob- 



542 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

ably free in the abdominal cavity. Large clots and masses are 
removed by the hand ; the remainder may either be floated out with 
the irrigating fluid, boiled water (preferably containing a half-tea- 
spoonful of common salt to the pint), or, what is often sufficient, the 
blood may be simply removed by sponging. Too much time must 
not be spent in attempting to remove every blood-clot. Let the 
pelvis be sponged and the abdomen closed. Drainage, as a rule, is 
necessary. 

If the patient has lost a large amount of blood and the pulse is 
very feeble, some of the irrigating saline fluid may with advantage 
be left in the abdomen ; also a saline enema containing stimulants 
may be administered. The question of infusion may have to be 
decided. 

Extraperitoneal Rupture. — If this event has occurred, as deter- 
mined by the physical signs given under Pelvic Hematoma — viz. 
the circumscribed tumor, the lateral fixed position, stricture of the 
rectum, etc. — the treatment is usually non-operative. The patient 
should be kept quiet. For the first few hours cold 'applications are 
of value ; later, heat, both externally in the form of poultices and 
per vaginam by hot- water douches, is required. 

In the majority of cases the pelvic hematoma thus formed will 
gradually be absorbed. There are, however, three possible indica- 
tions for a future operation : 

1. If the hematoma suppurates ; 

2. If repeated hemorrhages occur into the sac ; 

3. If fetal life continues. 

Occasionally, through infection from the rectum or from the 
uterus through the stump of the lacerated tube, suppuration of the 
hematoma occurs : it is then to be incised through the vagina, washed 
out, and thoroughly drained. If repeated hemorrhages are added 
to this hematoma, two courses are open, according to the size of the 
tumor. If comparatively small and situated low in the pelvis, it 
may be incised through the vagina, the clots and debris removed, 
and the cavity drained. If large and extending high in the pelvis, 
coeliotomy is probably the better operation. The broad ligament is 
incised and the blood-clots and products of conception are removed. 
If the contents of the sac appear aseptic, the sac may be sponged 
out and then closed. 

If for any reason the contents of the sac seem open to the sus- 



ECTOPIC GESTATION. 543 

picion of sepsis, the sac had better be stitched to the lower portion 
of the abdominal wound and drained. 

Fetal Life Continuing. — In the rare condition where fetal life 
survives the tubal rupture, new problems present themselves. We 
have seen above that in almost all cases this only happens when the 
rupture is extra-peritoneal, between the folds of the broad ligament. 
From the time of tubal rupture till the presence of a live fetus is 
thoroughly demonstrated, the patient is subject to the same rules of 
treatment as have been previously outlined. Subsequent to this 
event two lives have to be considered, and the life of the mother 
seems to be but little endangered by allowing the fetus to arrive at 
full term. Having arrived at a diagnosis, then, of a living ectopic 
fetus, the patient should be placed under close observation until the 
full period of fetal development. To wait, how^ever, until pseudo- 
labor has passed and the child is dead is neither scientific nor 
surgical. Having prepared for operation, an incision is made well 
to one side of the median line, so as carefully to avoid opening the 
peritoneal cavity ; the fetal sac is incised and the fetus is extracted. 
The chief point at issue in the whole treatment of a living ectopic 
fetus now presents itself: How shall we deal with the placenta? 
To strip it off from the tissues to which it is attached would usually 
mean terrific hemorrhage, and probably death of the patient. The 
best plan seems to be to stitch the fetal sac into the abdominal 
wound, thoroughly cleanse the sac, and pack it with gauze ; then 
to keep it clean and drained until the placenta comes away. Law- 
son Tait has recommended cutting the cord close to the placenta, 
washing out the sac, closing it hermetically, and leaving the placenta 
to be absorbed. This method of treatment, however, has not met 
with general acceptance. 

Occasionally the fetus will be found to have been dead for some 
time and the placenta loose. In this case of course they are both to 
be removed at the time of operation. 

There is one other condition the treatment of which requires con- 
sideration — viz. interstitial pregnancy with intraperitoneal rupture. 
Although rare, this condition needs prompt surgical interference if 
the patient is to be saved. The treatment is abdominal hyster- 
ectomy, and, as the element of time is all-important, the extra- 
peritoneal treatment of the stump is probably the method of 
election. 



DISEASES OF THE OVARIES AND TUBES. 



Anatomy and Physiology of the Ovary. 

The ovaries in the imman female are situated, one on each side 
of the uterus at the level of the brim of the true pelvis, in the pos- 
terior fold or leaflet of the broad ligament. The other two leaflets 

Fig. 327. 




Horizontal Section of the Abdomen immediately above the Crests of the Ilii : B, fundus of bladder ; U, 
uterine body; 0, ovary ; L, round ligament ; T, Fallopian tube ; V, sacrum ; E, rectum ; C, utero-sacral 

ligaments ; g, ureter. 

of the ligament are formed superiorly by the Fallopian tube and 
anteriorly by the round ligament. When the woman is in the erect 
position and the uterus in its normal situation, the ovary lies upon 
the ligament and looks upward and backward. The ovary is about 
an inch and a quarter long, three-quarters of an inch in width, and 
half an inch thick, convex upon the posterior and flattened upon 
the anterior surface, resembling in shape and size an almond ; the 
external extremity is blunt and rounded, the internal pointed, pro- 

544 



DISEASES OF THE OVABIES AND TUBES. 545 

jecting toward the ovarian ligament. It is connected with the 
uterus by the latter ligament, which is about one inch long. 

The normal ovary "weighs from ninety to one hundred and thirty- 
five grains. It is but partially covered by peritoneum, as is demon- 
strated by the contrast between the columnar epithelium of its pos- 
terior surface and the pavement epithelium of the peritoneum. The 
ovary consists of an external cortical portion, composed of cellular 
elements, and an internal medullary or fibrous portion, through 
which the blood-vessels, lymphatics, and nerves are distributed. 
The blood-vessels and nerves enter through the lower portion, 
which is called the hilum. 

At the fourth month of intra-uterine life the germinal epithelium 
and the stroma undergo a process of adhesion, by which masses of 
epithelium are aggregated in the stroma, forming tubes. Some of 
these tubes possess outlets to the surface of the organ. Some cells 
in the tubes early attain to considerable size, have a nucleus, and 
form the ova. The ova become isolated, and by further prolifera- 
tion of cells acquire a receptacle — the Graafian follicle. The germi- 
nal epithelium is divided by vascular stroma into two layers — an 
outer, composed of thin columnar cells, with one or two rows of 
round cells, which contain primitive ova, and an inner, thicker 
stroma between two layers of cells, which subsequently forms the 
tunica albuo:inea. 

The ovum originally consists of a nucleus and nucleolus, with a 
small amount of protoplasm. It is never situated in the centre of 
the follicle, but occupies the side most distant from the surface of 
the ovary. The number of ova in an ovary have been estimated 
as numbering from 36,000 to 400,000. It is evident that Nature 
has made provision for the loss of a large number in a rudimentary 
form. 

The formation of ova and egg-balls terminates with fetal life, 
but the isolation of the ova and transformation of egg-balls into 
follicles may be continued a couple of years later. 

The blood-vessels of the ovary are derived from the ovarian 
artery, analogous to the spermatic in the male, which comes off 
from the aorta. It anastomoses with the uterine, a branch of the 
internal iliac artery. 

The right ovarian vein enters the inferior vena cava at an acute 
angle and is supplied with a valve. The left enters the left renal 
vein at an angle and is without a valve. To this anatomical fact is 

35 



546 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



attributed the greater relative frequency of disease of the left ovary. 
The nerves enter the hilum as two fine twigs from the ovarian 
plexus. 

Puberty, — At birth the ovary is flattened and elongated. As 
puberty approaches it assumes an olive shape, which indicates the 
sexually mature female. This period is characterized by the advent 
of the intermittent discharge known as menstruation, supposed to 
be synchronous with ovulation. That these processes are not neces- 

Fm. 328. 




Ut, uterus ; 0, ovary ; Oa, infundibulum and abdominal aperture of the Fallopian tube and fimbrise ; Fo, 
fimbria attached to the ovary ; Po, parovarium ; io, marginal fold of broad ligament continued on to 
the infundibulum (infundibular ovarian ligament) ; ip, the same fold connecting the former with the 
pelvis ; Od, isthmus of the Fallopian tube ; Od', ampulla ; *, flmbrio-ovaric groove, lined by mucous 
membrane covered by ciliated epithelium ; LI, muscular striae under posterior layer of broad ligment : 
. Lo, muscular utero-ovarian ligament. 

sarily interdependent is evident from the fact that women become 
pregnant before the first occurrence of the menses, and, indeed, 
some have given birth to several children without ever having 
menstruated. Numerous cases are upon record where women have 
become pregnant after the occurrence of the menopause. 

Puberty generally takes place between the thirteenth and fif- 
teenth years. A well-established corpus luteum has been found in 
the ovary of a child which died at nine years. 

While it is indisputable that ovulation may occur without men- 
struation, it is to be doubted, notwithstanding the views of Tait, 
whether menstruation ever tak^s place in the absence of both of 
the ovaries. The cases in which menstruation has continued after 
the ovaries were removed are those in which a portion of the ovarian 



DISEASES OF THE OVARIES AND TUBES. 



547 



stroma was overlooked where it extended downward upon the ovarian 
ligament, or accessory ovaries were present, or there were tufts of 
ovarian stroma spread over the adjacent pelvic peritoneum. 

The mature human ovum measures ^h ^^ ^^ ^^ch in diameter. 
It is provided with a germinal vesicle which has a diameter of gfg- 

Fig. 329. 




Section of Ovary. 

of an inch, and within it a germinal spot whose diameter is 3^^ of 
an inch. As the ovum matures it moves from the centre to the 
periphery of the follicle ; induced by the secretion of liquor folliculi 
contained in its discus proligerus, it is impelled against the thinned 
wall. This wall consists of two lavers — an outer, the stroma of the 



Fig. 330. 



Fig. 331. 





Typical Corpus Luteum, fifteenth day from the 
besinninsr of menstruation. 



Freshly ruptured Follicle, twenty days after the 
beginning of the last menstruation. 



ovary, and an inner, the follicular epithelium. The ovisac is most 
vascular at the point of rupture, and as the ovum escapes into the 
peritoneum or oviduct the ruptured vessels bleed and fill up the 
space with a clot. This clot, as it contracts, becomes known as the 
corpus luteum. If fecundation of the ovum has occurred, the act 



548 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



of conception leads to greater vascularity and the formation of a 
large clot, designated the true corpus luteum to distinguish it from 
the false or small, less durable formation of ordinary unfecundated 
ovulation. 

The true corpus luteum is largest about the eleventh week, and 
continues to the end of pregnancy. The false rapidly becomes 
smaller and presents a bright and shining centre. The successive 
rupture of matured follicles leaves cicatrices upon the surface of 
the ovary. 

Fallopian Tube. — Projecting from each side of the fundus of the 
uterus, just posterior to the round ligament, and occupying the 
superior fold of the broad ligament, is the Fallopian tube. Its 
average length is about four inches, and its greatest width is at the 
outer extremity, called the fimbriated extremity, infundibulum, or 
morsus diaboli. Its orifice is called the ostium abdominale, and is 
surrounded by four or five large and eight or ten small fimbriae, 
which are continuous with the mucous lining of the tube, and one 
of which, the fimbria ovarica, extends to the ovary. The narrow- 

FiG. 332. 




Transverse Section of the Fallopian Tube of a Macaque Monkey. 

est portion of the tube is the inner or uterine end, an inch long, 
which is known as the isthmus. Its orifice is called the ostium 
internum. The diameter of the isthmus varies from one-twelfth 
to one-sixth of an inch, while the diameter of the ampulla, or outer 



DISEASES OF THE OVABIES AND TUBES. 



549 



portion of the tube near the ostium, is from one-fourth to one-third 
of an inch. At its origin the tube is directed upward and backward; 
the ampulla curves upon itself until the infundibulum or fimbriated 
extremity is directed toward the ovary. The fimbria ovarica has 
upon its upper surface a groove bordered by small fringes or fim- 
briae. Along this furrow passes the ovum to the oviduct as it 

Fjg. 333. 




Recess of the Tubal Mucous Membrane of the Panoliau Deer; 



escapes from the ovary, doubtless facilitated by the current pro- 
duced by the wave-like motion of the cilia. 

The Fallopian tube has three coats of layers — the peritoneum, 
which does not completely encircle it, formhig a mesosalpinx ; the 
muscular, consisting of longitudinal and circular fibres ; and the 
internal coat, consisting of the mucous membrane. The latter is 
thrown into longitudinal furrows and projections. Comparison of 
Figs. 332, 333 and 334 shows that the arrangement of the folds of 
the tube is much more complex than it is in the human female. These 



550 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



folds possess the characteristics of glandular structure. The mem- 
brane is lined with ciliated columnar epithelium. " The function 
of the latter," says Tait, " is to expedite the passage of the ovum 
to the womb, and to limit the opportunity for entrance of the sper- 
matozoa." This theory obligates conception, as a rule, to occur in 
the uterus, but the repeated occurrence of ectopic gestation, in cases 
in which careful examination has failed to disclose any abnormal 
condition of the membrane between the gestation-sac and the uterus, 
goes far to discredit the theory. 

The most important change taking place at puberty is in the 
structure of the tube. It becomes more vascular, its muscular 
structure is develojDcd, and the epithelial layer is fully formed. 
These changes result in the functional movement through which 

Fig. 334. 




Transverse Section of the human Fallopian Tuhe. 

pregnancy is rendered possible. As has already been noted, ovula- 
tion has repeatedly occurred prior to puberty, but the ovum has 
been lost in the peritoneal cavity. Ovulation may continue after 
the menopause, though the ovaries have become atrophied, but the 
tubes will then have become straightened, and again fail to carry 
the ovum to the uterine cavity. 

The ovary and tube are situated in the folds of the broad liga- 
ment, the superior fold being occupied by the latter. The ligament 
is continued to the ileo-pectineal line by the infundibulo-pelvic liga- 
ment. Between the tube and ovary, and within the fold of the 
broad ligament, is an embryonal body, which consists of a number 
of small tubes and cysts, and is known as the parovarium or organ 
of Eosenmiiller. It is most probably the remains of the Wolffian 



DISEASES OF THE OVABIES AND TUBES. 551 

body. The tubes of which this body is composed sometimes ex- 
tend into the hilum of the ovary, and thus afford, according to 
some authorities, a congenital source of origin for some forms of 
ovarian cyst. A small, thin-walled cyst, known as the cyst or 
hydatid of Morgagni, hangs from the posterior surface of the 
Fallopian tube by a long pedicle. It has no pathological sig- 
nificance. 

Malformations of the Ovary and Tube. 

Congenital absence of both ovaries occurs but rarely. When 
this malformation occurs, it is generally associated with defective 
development of the uterus. In such patients the physical changes 
in conformation incident to puberty do not occur, and the individual 
more closely resembles in appearance the male. When one ovary 
is absent, there is likely to be a deficiency in the development in the 
corresponding half of the uterus and tube. In a number of cases 
there has also been an absence of the corresponding kidney. A 
third or accessory ovary is very infrequent. 

Doran asserts that small fibro-myomata in the ovarian ligament 
have been mistaken for supernumerary ovaries. Small islets of 
ovarian tissue have been found upon the peritoneum. Such a con- 
dition or the incomplete removal of an ovary undoubtedly has 
been the cause of menstruation subsequent to oophorectomy. 

Where the ovaries are absent or marked failure in their develop- 
ment has occurred, the sexual functions are never performed nor- 
mally. The absence of one ovary or its serious involvement by 
disease constitutes no obstacle to either sexual intercourse or con- 
ception. It is very important to determine, if possible, that the 
ovaries are absent or rudimentarv, as when these conditions are 
once recognized the absolute futility of any measures to establish 
menstruation is demonstrated. 

Malformations of the Tubes consist chiefly in defective de- 
velopment of the fimbriae at their abdominal ends. The tube may 
be unusually short or have supernumerary ostea or openings. These 
openings may be provided with fimbriae or the latter may be absent. 
An unusually convoluted tube is sometimes observed, evidently due 
to its defective development, resembling the condition seen in women 
prior to puberty. At times the convolutions of the tube form actual 
strictures, which contract its cavity sufficiently to render the woman 
sterile. 



552 ^iV^ AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Displacements of the Ovary and Tube. 

Hernia through the inguinal canal is a rare condition. It is 
generally found upon the left side. Hernia of the ovary may 
occur without the presence of any other organ in the hernial sac, 
unless it be the Fallopian tube. The presence of the ovary is 
generally secondary, however, and results from adhesions to the 
omentum and the intestines. 

Most probably the first surgical removal of the ovaries was per- 
formed by Potts for ovarian hernia. The displaced organs may 
jeadily be mistaken for glands or labial tumors. The constant 
presence of a tumor, its physiological character, the dull, sickening 
pain, and extreme nausea, should aid in the diagnosis. The ovary 
has also been known to make its exit through the crural canal, the 
greater sacro-sciatic foramen, and the umbilicus. Such displaced 
organs may become cystic. Chenieux has reported a cyst of this 
variety in the right buttock which was mistaken for a lipoma. 

Treatment. — Taxis should be judiciously and carefully exer- 
cised, the ice-hag or the sand-bag may be applied, and after reduc- 
tion has been effected a truss should be worn. If the symptoms are 
annoying and reduction cannot be accomplished, the sac should be 
incised and the ovary replaced or removed, according to its condition. 

Prolapsus Ovarii. — Displacement of the ovary may be depend- 
ent upon, or independent of, the position of the uterus. When the 
latter organ is retroverted, the ovary follows from traction through 
the ovarian ligament. In retroversion the ovary usually lies in 
front of the uterus, but it sometimes lies beneath that orgaa in the 
cul-de-sac. The ovary may be displaced and the uterus retain its 
normal position. The prolapsed ovary is exceedingly tender; the 
most frequent symptom is pain during or after defecation. The 
j^aroxysm thus produced may, in some cases, last an hour or more. 
Other symptoms are painful coition, dysuria, and dysmenorrhea. 

Etiology. — Prolapsus is generally a sequel of gestation ; the 
broad ligament becomes extended and the infundibulo-pelvic liga- 
ment may give way. Enlargement of the ovary from chronic 
inflammation or perimetritis may be important factors. 

Diagnosis. — The diagnosis is made by the determination through 
vaginal and rectal examination of a mass in Douglas's pouch, which 
is movable, may be pushed upward, or whose pedicle can be distin- 
guished by dragging upon the tumor. It is exceedingly sensitive, 



DISEASES OF THE O VARIES AND TUBES, 553 

and pressure upon it produces a peculiar sickening sensation simi- 
lar to that induced by pressure upon an inflamed testicle. If severe 
inflammation has occurred, the ovaries and tubes may be fixed be- 
hind the uterus. 

Treatment. — The first consideration should be rest. The bow- 
els must be carefully regulated and the marital relation be abso- 
lutely prohibited. The patient may be placed in the genu-pectoral 
position and the organs pushed up and maintained by a suitable 
pessary. The Thomas and Munde pessaries prove the most satisfac- 
tory, as their thickened posterior bar affords more efiicient support 
and decreases the possibility of the organ being pinched between 
the pessary and the sacrum. The occurrence of this accident is 
attended with agonizing pain, rendering the patient unable to move 
until the pressure is removed. When various pessaries have been 
unsuccessfully tried, and the patient is incapacitated for her duties, 
abdominal section should be performed, and ovarian fixation effected, 
either by restoring the infundibulo-pelvic ligament or suturing the 
pedicle of the ovary to that part of the anterior parietes corre- 
sponding to the exit of the round ligament. This operation may 
be associated with ventro-fixation of the uterus, when retroversion 
of that organ complicates the displacement. Descent of the ovary 
alone never justifies extirpation. The latter procedure should only 
be considered when the displacement is associated with marked 
oophoritis or perioophoritis. 

Congestion of the Ovaries. — The ovaries are physiologically 
congested in ovulation and during coition. This congestion in excess 
or prolonged becomes pathological. An over-congestion of the ova- 
ries is not infrequent at the establishment of the menstrual function, 
especially in individuals in whom the mental faculties have been 
developed at the expense of the physical structure. Girls are 
often too closely confined to school and to the study and practice 
of music when Nature is exhausting her forces in their develop- 
ment. Blood may extravasate into the follicles and stroma of 
the ovary, more frequently into the former. The hemorrhage 
into the follicles may distend the ovary to the size of a hen's 
Qgg or even to that of an orange. Later, this is converted into 
a pigment the consistency of honey, having a rusty chocolate color. 
Winckel has reported similar conditions associated with heart dis- 
ease, typhoid fever, phosphorus-poisoning, and in extensive burns. 
The follicle generally does not rupture, but the ovarian tissue is 



554 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

completely destroyed. A case came under the observation of the 
author in which each ovary was distended to the size of a small 
orange, and consisted of thin-walled cysts filled with dark grumous 
blood. Follicular apoplexy, as well as ovarian congestion, gener- 
ally occurs in the sexually immature. It may terminate in absorp- 
tion, or the ovary may rupture and a large hemorrhage take place 
into the peritoneal cavity, causing fatal peritonitis. 

The principal symptom of congestion of the ovary is pain in 
the lateral regions of the pelvis, for a week or ten days prior to the 
appearance of the flow, and becoming lighter or disappearing with 
its cessation. The escape of blood relieves the engorged oi'gans, 
and the only period of comfort is experienced during menstruation. 
The flow is prolonged and excessive, frequently amounting to a 
hemorrhage. The patient becomes weak, pale, and anemic. 

Diagnosis. — The existence of this condition should be suspected 
from the age, near puberty — the excessive and prolonged flow, 
anemic appearance, weakness, pain and tenderness over the pelvis — 
which is generally more marked upon the left side — and not infre- 
quently pain in the corresponding mammary gland. Apoplexy is 
rarely recognized, as it presents no distinctive symptoms. 

Tekmination. — Ovarian congestion under proper hygiene and 
treatment may disappear. Where it continues it is transformed 
into chronic inflammation. The collections of blood in follicular 
hemorrhage may be absorbed, leaving an enlarged cicatrix, or they 
may break down and destroy the ovarian structure, forming an 
ovarian hematoma. Extensive hemorrhage with rupture of the 
ovary may cause pelvic hematocele, or even death. 

Tkeatment. — Attendance upon school, and particularly the 
study of music, should be discontinued ; the reading of emotional 
literature interdicted ; and out-door pursuits encouraged, such as 
riding and walking. City girls should be sent to the country or 
sea-shore. The bowels should be carefully regulated and a gener- 
ous diet aflbrded, from which sweets and pastry must be largely 
excluded. A morning sponge-bath, followed by friction with a 
coarse towel, will be serviceable. Kest in bed for a few days prior 
to and during the entire menstrual period should be the rule. If 
the flow is excessive, the period should be preceded for a few days 
by the administration of the fluid extract of ergot, 3ss, or of 
ergotin, gr. ij, in capsule, three or four times daily and continued 
until the flow ceases. During the menstrual intervals potassium 



DISEASES OF THE OVARIES AND TUBES, 555 

bromide, gr. xv, or potassium chlorate, gr. v, administered three 
times daily, with such tonics as quinine, strychnine, and the bitter 
tinctures, is required. 

The anemia may tempt one to resort to the use of the saUs of 
iron, but experience teaches that this remedy is of service only after 
the tendency to hemorrhage has ceased. Its earlier administration 
but aggravates the tendency to bleeding. 

Oophoritis and Perioophoritis. 

Inflammation of the ovary may be acute or chronic. Anatomi- 
cal distinctions of parenchymatous, follicular, and interstitial are 
made, but such distinctions are rarely determined clinically. 

Acute Oophoritis. 

In acute inflammation the ovary becomes enlarged, filled with 
cysts, or is oedematous ; the cysts are filled with a cloudy serum 
looking like pus. The ovary may in a few days become three 
or four times its normal size. The cut surface will exude a 
large quantity of serous fluid, while in more severe grades a 
number of purulent yellow streaks will be seen starting from the 
hilum. A smeary mass will be discharged in some cases, while in 
others there will be the distinct pus-collection of an abscess. The 
organ may attain to the size of a man's head, though generally it 
is not larger than a hen's egg, when it produces the sensation to 
the examining finger of a firm mass. An inflammation of the 
ovary may progress to the formation of an abscess, and subse- 
quently the watery contents be absorbed, leaving a cheesy mass. 
In the milder forms of inflammation resolution may take place. 
The connective tissue undergoes retraction, depressing the surface 
here and there, producing premature involution or cirrhosis of 
the ovary. The ovary may be reduced to the size of a hazel- 
nut. This form of inflammation is prone to affect both ovaries, 
while the abscess is usually found in but one. In perioophoritis 
the capsule of the ovary becomes thickened ; the entire organ is 
bound down by perimetric bands of adhesions. The thickening of 
the capsule renders it less likely to rupture with the ripening of the 
Graafian follicle, and a small cyst remains. Under the influence 
of disturbed circulation a large number of follicles may mature at 
once, producing a cystic ovary. The partitions frequently break 
down, and a large cyst is formed. 



556 AN AMEBIC AN TEXT-BOOK OF GYNECOLOGY. 

Etiology. — The principal causes of acute oophoritis are — injury, 
septic poisoning after parturition or abortion, gonorrhea, arsenical 
or phosphorus-poisoning, the exanthemata, acute rheumatism, and 
long-continued endometritis. 

Sepsis, without doubt, is the most frequent cause ; the next 
frequent is gonorrhea. Septic inflammation is very likely to 
result in abscess and a more or less extensive peritonitis. The 
left ovary is more prone to be the seat of such a destructive pro- 
cess, due, according to some authors, to the difference in its circu- 
lation. Gonorrhea produces perioophoritis with a binding down 
of the ovary by adhesions. 

Symptoms. — The patient complains of intense, lancinating pain, 
generally over the left inguinal region, associated with extreme ten- 
derness, elevated temperature, rapid pulse, and frequent chills. In 
perioophoritis the symptoms are less marked than those of mild 
peritonitis. 

CouKSE AND Termination. — Acute oophoritis may terminate in 
resolution and disappearance of the abnormal symptoms, the devel- 
opment of an abscess, its rupture, and the occurrence of a rapidly- 
fatal infective peritonitis, or the disease may become chronic. 

Treatment. — The treatment should consist in absolute rest in 
bed, the administration of salines until free purgation is secured. 
Tincture of aconite, gtt. j-ij every hour, is of value. Leeches may 
be applied to the perineum and an ice-bag to the seat of pain, or, 
where better borne, hot fomentations with opium, or morphine 
given by the rectum may be applied, or where pain is very severe the 
morphia may be given hypodermically. When an abscess forms, 
the only acceptable treatment is surgical, as considered elsewhere. 

Chronic Ovaritis. 

Chronic inflammation is much more common than the acute dis- 
order. It occurs during the period of sexual activity, and more 
frequently in the married. The ovary may be enlarged, presenting 
a number of cysts with little interstitial growth or increase of the 
fibrous tissue of the organ ; subsequent atrophy, known as cir- 
rhosis, occurs. The ovary may be fixed in the pelvis by an 
extensive infiltrate, so that it is immovable and scarcely to be 
distinguished, or it may be movable and prolapsed into the retro- 
uterine pouch. 

Etiology. — Chronic ovaritis may be the sequel of the acute 



DISEASES OF THE OVARIES AND TUBES. 557 

disease and due to the same causes. It is also produced by exces- 
sive sexual intercourse, masturbation, sexual excitement without 
gratification, suppressed menstruation, and to operations upon the 
cervix. 

Symptoms. — Pain is an inevitable feature, experienced with the 
greatest intensity in the groin and with the greatest frequency upon 
the left side. It is persistent, increased by locomotion, by a misstep, 
or by jolting. It is greatly exaggerated as the menstrual period ap- 
proaches. If the flow is free, amounting to a menorrhagia, the pain 
is relieved or may disappear ; if it is but slight, the pain increases. 
When the pain from any cause is intensified, it extends down the 
thighs and over the sacrum. Not infrequently pain is felt in one 
or both mammary glands of such intensity as to lead the patient to 
suspect the existence of malignant disease. Symptoms of spinal 
irritation and attacks of migraine are frequent near the menstrual 
periods. Hysteria or hystero-epilepsy may be an accompaniment. 
Sterility is an almost constant result. The ovaries are generally 
tender to pressure, though they may not be to any considerable 
degree enlarged. When prolapsed behind the uterus with that 
organ resting upon them, they are sensitive to the slightest pressure, 
and cause pain in defecation, and especially in coition. Frequently 
the marital relations are so painful and produce so much distress 
that they are necessarily discontinued. Physical examination must 
be conducted with great care. When the organs are prolapsed and 
fixed behind the uterus by inflammatory exudate, the careless 
observer mav mistake the condition for retroflexion of the uterus. 

Diagnosis. — The determination of large and sensitive ovaries, 
exaggerated distress for a week or ten days prior to menstruation, 
mammary pain, with painful defecation and coition, leave but little 
room for doubt. When the physical signs obtained by vaginal 
touch are obscure, rectal examination will be of great service and 
should be a routine practice. Where the abdominal walls are 
rigid or the pelvic organs very sensitive, an examination under 
anesthesia may be of value in supplementing or confirming the 
diagnosis. 

Treatment. — Where it is possible, the removal of the sources of 
irritation which have led to the production of the disease should be 
the first consideration. The marital relation should bie suspended 
or infrequently practised ; vigorous exercise or long standing upon 
the feet should be avoided. The patient should rest in bed during 



558 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



menstruation. Blood may be abstracted by leeches to relieve 
severe pain. Counter-irritation with iodine, blisters over the 
region of the ovaries, or mercurial inunctions may be beneficial. 

Internally, the administration of the potash salts, as the iodide, 
bromide, or chlorate, alone or in association with the bitter tonics, 
as nux vomica and cinchona or their alkaloids, strychnine or 
quinine, often give marked relief. 

Benefit has been claimed from the following: 



^^. Auri et sodii chloridi, 

Extractum cannabis indicae, 
Ft. cap. 
Sig. Take one capsule three times daily. 



1 . 

20 ? 



gr 

gr. ss 



-M. 



Ichthyol may be given by the mouth,^ vaginal suppository, or by 
inunction over the lower abdomen. The bowels should be carefullv 
regulated. Fixation of the ovaries may be overcome by the judi- 
cious use of pelvic massage. The severity of the attacks of pain may 
be much ameliorated by the administration of ten drops of tincture 




Diagram of the Structures in and adjacent to the Broad Ligament : 1, la, multilocular cystic tumor, devel- 
oped in 1, parenchyma of the ovary ; 3, papillomatoTis cystic tumor of the ovary in 2, tissue of the 
hilum of the ovary ; 4, simple broad-ligament cyst, independent of the parovarium, 10, and the Fallo- 
pian tube ; 5, a similar cyst in the broad ligament above the tube, but not connected with it ; 6, a similar 
cyst close to 7, ovarian fimbria of the tube ; 8, hydatid of Morgagni (this never appears to form a large 
cyst) ; 9, cyst developed from the horizontal tube of the parovarium ; 11, cyst developed from a ven- 
tricle tube (cysts of this kind form the papillomatous tumors of the broad ligament) ; 12, 13, tract of 
the obliterated duct of Gaertner (papillomatous cysts are said to be developed along this tract). 

of Pulsatilla, four times daily preceding the expected attack, and 
continuing it until the menstrual flow has been well established. 
In severe cases, or where all palliative measures have failed to 
render the patient comfortable, the offending organs should be 
removed. 



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DI8EASE8 OF THE OVARIES AND TUBES. 559 

OvAEiAN Neoplasms. — The neoplasms of the ovary may be 
divided clinically into cystic and solid growths. The cystic tumors 
include simple, proliferating, and dermoid cysts. The solid tumors 
are fibromata, sarcomata, and carcinomata, and are comparatively 
rare. Cysts may originate in any part of the tubo-ovarian 
structure, as the cortical, medullary, or parenchymatous struct- 
ure of the ovarv ; in its inferior border or hilum ; in the 
structures between the tube and ovary known as Rosenmiiller's 
organ or the parovarian structures ; and in the hydatid of Morgagni, 
the extremity of the canal of Miiller. Cysts are also developed in 
the folds of the broad ligament, and are known as broad-ligament 
cysts. The cysts may be unilocular with limpid contents, or multi- 
locular with contents varying in different cysts, some clear and 

Fig. 336. 




Broad-Ligament Cyst, Fallopian Tube and Ovary. 

limpid, others thick and viscid or discolored with the admixture of 
blood, pus, or fat. The broad-ligament cysts are generally unilocu- 
lar, containing clear fluid ; those originating in the hilum, papillary ; 
and in the parenchymatous tissue of the ovary, glandular. 

Tlie cysts may be divided pathologically into simple, proliferating, 
dermoid, and parovarian, or^ according to size, into small and large 
cysts. 

Under small cysts may be described, first, small residual cysts 
developing from Morgagni's hydatid or the horizontal canal of the 
parovarium ; second, follicular ; third, cysts of the corpus luteum ; 
and fourth, tubo-ovarian cysts. 

The large cysts include, first, the glandular proliferous ; second, 
the papillary proliferous ; third, dermoid, simple or mixed ; fourth, 



560 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

parovarian, including several varieties, as hyaline, papillary, and 
dermoid. 

Cysts of the Hydatid of Mokgagni. 

Attached to the fimbriated end of the Fallopian tube is generally 
found a cyst varying from the size of a pea to that of a cherry. 
It is transparent and has a thin walh This hydatid is the remains 
of the extremity of Miiller's canal, and is rarely absent. The 

Fig. 337. 




Cyst of the Organ of Morgagni. 

length of its pedicle varies in different individuals. It is some- 
times nearly an inch in length and very thin ; in other cases it is 
short and thick. Doran describes a supra-tubal cyst about the 
size of the former and of the same appearance and structure. 
It is supposed to be a micro-cyst of the broad ligament which 
has slipped under the serous membrane and attained this unusual 
position. 

MiCEO-CYSTS OF THE BrOAD LiGAMENT. 

These are small cysts which develop in the structure or are sus- 
pended from E-osenmiiller's organ ; other cysts are found free, 
and are of undetermined origin. Only those which originate 
from the vertical tubes of the. parovarium have ciliated epithe- 
lium, and are likely to subsequently develop into papillary 
growths. The others, and even those which start in the hor- 
izontal tube, may become detached from the broad ligament and 
hang by a slender pedicle. These micro-cysts may possibly be 
the starting-points for large cysts with either fluid or papillary 
contents. 



DISEASES OF THE OVARIES AND TUBES. 561 

Simple or Follicular Cysts/ 

These cysts are formed from unruptured Graafian follicles which 
become dilated. In an ovary which has not attained to twice its 
normal size may be found fifteen or twenty of these cysts. They 
were long considered as the only source of large ovarian cysts. It 
has, however, been discovered that it is only in rare cases that they 
attain to the size of a fist, or, at the utmost, to that of a man's head. 
They contain a light serous fluid with a specific gravity of 1005 to 
1020. The cyst- wall is thin, has a light gray color, and is in large 
part a transparent membrane. The disease is generally bilateral. 

Etiology. — These cysts, even when of large size, are regarded 
as dilated Graafian follicles, because of the different gradations 
observed between them and the smaller cysts. In the smaller size 
ovula may be detected, which may have been destroyed or have 
escaped observation in the larger. 

Dropsy of the follicle is occasioned by its failure to rupture with 
the increase in its fluid contents. The rupture may be prevented 
by its deep, situation, thickening of the tunica albuginea, or deposits 
of peritonitic exudation over the surface of the ovary. It may also 
be caused by too slight a menstrual congestion, which, though in- 
creasing the secretion, is insufiicient to produce rupture. 

• 
Cyst of the Corpus Luteum. 

This cyst was first described by Rokitansky, who believed that 
the corpus luteum of pregnancy only could be transformed into a 
cyst, but such cysts have been found in the nulliparae. They are 
generally not larger than a walnut, but cases have been described in 
which they have attained the size of an orange or an apple. Nagel 
even speaks of one which had reached the size of the adult head. 
Microscopical examination shows the bud-like papillae in the walls 
characteristic of the corpus luteum. The recognition of this pre- 
vents their confusion with follicular cysts, or even with suppurative 
ovaritis. 

TUBO-OVARIAN CySTS. 

The presence of an ovarian cyst not infrequently results in the 
formation of a tubo-ovarian cyst through its proximity to a dis- 
tended tube. Tubal inflammation early results in fastening the 
ostium of the tube to the ovary by firm adhesions. A dilated fol- 
licle or a small cyst may readily rupture into a distended tube, with 

36 



562 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



which it is in juxtaposition, and form one sac, the smaller part of 
which is generally furnished by the tube. They do not usually 
attain to a large size. The Fallopian tube may remain permeable, 
and as the fluid increases the overflow passes into the uterus ; a con- 
dition known as profluent ovarian hydrops is thus formed. It may 
be compared with the condition engendered by hydrosalpinx known 
as profluent hydrops tubge. The open tube may act as a safety- 
valve, preventing the growth and over-distension of the cyst, 
and in some cases leading to its complete prolapse after every 
evacuation. 

Large Cysts. — Proliferating Cystomata. 

The term " proliferation," as applied to cysts, refers to those which 
are highly organized and abundantly supplied with blood-vessels. 

Fig. 338. 




,'/-#' 



<#^ ■::-Sm J^'^- 

" ' . ■''"'///^lil'i'n'-'' 

''■',; ''/■/t,"'''i'-' ' 



'//■:/' 



Large Ovarian Cyst, weighing 149 pounds. 



The term " proligerous cysts " is also applied to them, and indicates 
their faculty of budding and generating new cysts from or within 



DISEASES OF THE OVARIES AND TUBES, 



563 



tlie original growth. In shape they may be spherical and regular 
in outline, simulating the jDi'esence of a single cyst, or irregular, 
presenting nodules, indicating a multilocular tumor. 

They may vary from the size of an egg to that of a tumor weigh- 
ing more than one hundred pounds, filling up the entire abdomen 
and encroaching upon the thoracic viscera. When exj)osed the 
cysts present a pearly-white, glistening appearance. The thinner 
portions are purple, green, or black according to the color of their 
individual contents. The external surface may be smooth and oily, 
covered with papillary growths or mucous vegetations. The tumor 
generally has a distinct pedicle. The consideration of the internal 
structure of ovarian cysts justifies their division into areolar, uni- 
locular, and multilocular. 

Areolar. — When an areolar cyst is opened it is found filled with 
spurs or trabeculse of small cysts which have ruptured to form a 
large main cyst, or it may be made up of a large number of small 



Fig. 339. 




Proligerous Glandular Ovarian Cyst of areolar appearance. 

cysts bound together by loose connective tissue almost gelatinous in 
appearance. In a tumor of this kind, removed from a young 
woman, a large number of small cysts were found. Although the 
tumor was as large as a pregnant uterus at full term, it contained no 
cyst larger than a good-sized plum. 

Unilocular cysts attain to an enormous size, but are found to 



564 AJV AMERICAN TEXT-BOOK OF GYNECOLOGY, 

contain evidences of previous division into smaller cysts, and it 
may be asserted that all unilocular cysts arise from the multilocular : 
even in the large tumors close examination will disclose small cysts 
in their walls. 

Fig. 340. 




Multilocular or Glandular Cystoma. 

Multilocular cysts are so called because they contain a number 
of cysts of nearly equal size, so arranged as to present the appear- 
ance of one large cyst. 

The cyst-wall can be divided into three layers — an outer and 
an inner of fibrous, and a middle layer of connective, tissue. In 
the latter the vascular supply is distributed, and it sometimes con- 
tains vessels as large as the femoral vein. In areolar cysts these 
vessels can be seen coursing upon the surface, and when wounded 
may cause dangerous or even fatal hemorrhage. Large vessels are 
frequently found free in the gelatinous contents of large cysts, and 
remain after the destruction of the former septa. Such vessels may 
be the source of hemorrhage into the cyst. 



DISEASES OF THE OVABIES AND TUBES. 



565 



The external surface of the cyst is covered by columnar epithe- 
lium diifering from the pavement epithelium of the peritoneum. 
The internal surface is lined by low cylindrical cells. Section of 
the cyst-walls shows depressions of the endothelium resembling 
acinous glands with a narrowed opening. The lining membrane 
may be covered with vegetations formed from proliferated stroma, 
simulating myoma or fibro-sarcoma. These tufts are covered with 
a single layer of endothelium. Epithelial prolongations of a tubular 
form may penetrate from below upward, presenting the appearance 
of carcinoma. 

The contents of the cysts often present marked contrasts in 

Fig. 341. 




Portion of an Ovarian Adenoma, showing the varieties of loculi : c, primary ; d, secondary. 

color or consistency; thus they may be found either almost colorless, 
straw-colored, green, purple, or black in color, thin, and thick, viscid, 
or gelatinous in consistency. The contents may vary in color and con- 
sistency in different cysts of the same tumor. The fluid in the smaller 
cysts is generally more consistent and becomes thinner as they increase 
in size, the result of changes in the structure of the epithelium. 



666 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Proliferating cysts may be divided into two classes : first, those 
in which the vegetations are derived from the epithelium and from 
glandular tubes, proliferous glandular cysts, or adenomata ; second, 
those in which the connective tissue of the walls develops and pro- 
jects as vegetations — proliferous papillary cysts. These cysts do 
not differ essentially in their origin. 

The walls of the cysts may undergo the following degenerative 
or retrogressive processes : 

1. Calcification most frequently takes place in the inner layer of 
the main cyst-wall as deposits of granules or small plates of lime 
or the formation of psammatous bodies, as seen in the papillary 
cystomata. The calcification increases with impairment of nutrition, 
as occurs in gradual torsion of the pedicle. 

Fig. 342. 




Calcified Corpus Luteum : A, calcified portion; B, interior of the corpus luteura. 



2. Fatty degeneration occurs in the papillary cells, which are 
regenerated, while the desquamated fatty cells are destroyed. A 
similar change takes place in the connective tissue and walls. The 
process is enhanced by any impairment of nutrition. The pressure 
of cyst-contents induces this change in the septa, resulting in their 
partial or complete destruction. The presence of a large amount of 
fat in the fluids is indicative of slow growth. 

3. Atheromatous changes, which generally take place in the inner 
layer of the wall. 

4. Changes due to infarctions in which whitish opaque bodies 
will be found in the septa surrounded by a red zone. 

Papillary Cystomata, — These cysts were formerly regarded as a 
variety of the glandular. They are believed to have developed from 
the paroophoron, in the broad ligament, or in the prolongations of 
its tumors into the hilum of the ovary. They differ from ordi- 
nary ovarian or oophoritic cysts in that, first, they produce no effect 
upon the shape of the ovary until they have attained a large size ; 
second, they burrow beneath the layers of the mesosalpinx, and 
when of large size separate the layers of the broad ligament beside 



DISEASES OF THE OVARIES AND TUBES. 



567 



the uterus ; third, their interior is filled with warty growths. These 
warts form cauliflower growths, or masses which over-distend and 
rapture the cyst-walls, from which they extend to the adjacent 
organs, particularly the peritoneum. The cysts rarely attain to 
large size, and in the majority of cases are bilateral. 

When the cyst ruptures, the dendritic masses infect the perito- 
neum, producing growths upon the adjacent tissues. These are 



Fig. 343. 




Dermoid Cyst containing long red hair, removed from a light-haired woman aged 44 years. 

reddish or pearly- white and glistening masses, or in some cases 
growths three or four inches long projecting in every direction 
and having the appearance of stems of coral. These masses have 
usually partly undergone calcification, so that they break easily and 
without bleeding. 

These tumors are characterized by slow growth, by frequent and 
early pressure-symptoms, and generally by the early presence of 
ascites, which soon returns after puncture. 



568 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

The writer has had a number of cases of the growths under 
observation. In a recent one the involvement was bilateral and 
beneath the peritoneum, dissecting it off from the posterior surface 
of the uterus and obliterating the retro-uterine cul-de-sac. A large 
quantity of ascitic fluid was drawn off, when the entire peritoneum, 
parietal and visceral, was found studded with small red masses. In 
another patient the entire surface of the uterus and broad ligaments 
was covered with dendritic masses three inches long, which had 
become partially calcified. Specimens of such growths are repre- 
sented •in the illustrations. The danger of peritoneal infection pre- 
cludes tapping when there is any reason to suspect such a growth. 

Ovarian Dermoids. — Dermoid tumors are those in which are 
found skin or mucous membrane associated with the structures 
generally connected with such tissues. The tissues most frequently 
found are hair, teeth, nails, sebaceous and sweat-glands, and mam- 
mae, horn, bone, unstriped muscular fibre, and, in rare cases, a tissue 
resembling brain. The hair varies in color, length, and quantity. 
It is not always of the same color as that of the person from whom 
the tumor is removed. The sebaceous glands are numerous and 
produce an extensive accumulation of fatty material. The teeth 
are irregular, generally imperfectly formed, though presenting the 
structures of dentine and enamel. They vary in number from two 
or three to several hundred. They may dot the surface of a mem- 
brane or be inserted in thin spicula of bone. The bone is gener- 
ally loose, ill-formed, and irregular. 

These growths may appear at any age. They have been found 
in children at birth and in women of ninety years. A tumor 
removed from a girl aged eleven years had been noticed when but 
eight years of age. It involved both ovaries, and the fundus was 
imbedded in the mass. The neck of the uterus was made to form 
the pedicle. The tumor contained a large quantity of sebaceous 
material — hair, bone, teeth — and at one point a mass resembling 
one side of the upper jaw covered with mucous membrane and 
containing a row of teeth. 

Fig. 343 was removed from a woman aged forty-four years, who 
had given birth to six children. It contained hair and sebaceous 
material. Cullingworth reports a woman, in whom both ovaries 
were apparently involved by dermoids, who had given birth to 
twelve children and had three miscarriages — the last three months 
before the removal of the growths. 



PLATE XXXVI. 









Dermoid Cyst Laid Open, showing Maxillary Bone containing teeth ; the head of one of tlie long bones; 
skin with hair growing from its surface; serous membrane (probe passed underneathj ; mucous mem- 
brane of stomach directly next to serous membrane. 



DISEASES OF THE OVARIES AND TUBES. 



569 



The rupture of ovarian dermoids is followed by jieritonitis. The 
irritating character of their contents contraindicates puncture prior 
to their removal. The writer has seen a case in which an attempt 
at aspiration was followed by an attack of peritonitis which proved 
fatal, notwithstanding ovariotomy was performed three days later. 

Solid Tumoes of the Ovary. — The solid growths of the ovary 
comprise 5 per cent, of the cases which present themselves for ope- 
ration, and may be divided into three groups : the fibro-myomata, 
sarcomata, and carcinomata. The first group is frequently divided 
into two groups : the fibromata and myomata. The former are rare, 
and comprise those growths in which the minute structure consists 
of wavy bundles of fibrous tissue closely packed, intermixed with 
small round cells. In a few instances these growths attain a large 

Fig. 344. 




Calcified Fibroma of the Ovary. 

size. Williams described .one which weighed seven pounds seven 
ounces ; Doran, one of seventeen pounds. The myomata are more 
frequent than the former, but are not common. These tumors are 
prone occasionally to undergo calcareous degeneration, and are 
under these circumstances often mistaken for osseous tumors — a 
variety of ovarian degeneration which rarely if ever occurs. 

Unstriped muscular fibre occurs in the ovary as a continuation 
of the ovarian ligament. Tumors of the ovary composed of this 
tissue sometimes attain to large size. Sutton mentions a specimen 
in the Museum of the Royal College of Surgeons removed from a 
woman aged 68 years, which weighed fifteen pounds two ounces. 

Sarcomata of the ovaries differ from those diseases in other j)arts 
of the body in that both organs are likely to be affected simulta- 
neously. They may belong to the spindle- or round-celled varieties. 



670 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



The former are the more frequent. The majority of solid ovarian 
tumors will be found to belong to this class. Sarcomatous tumors 
grow rapidly. Carter describes a specimen which attained a weight 
of ten pounds in six months. 



Fig. 345. 




Showing the Structure of Calcified Fibromata. The darker portions represent areas of calcification. 

Caecinomata. 

Cancer of the ovary is rarely primary. It generally is secondary 
to ovarian adenomata. The latter possess, with carcinomata, a 
common feature in the presence of epithelium arranged in a definite 
manner, and experience has shown the tendency of carcinoma to 
develop upon adenomatous growths. Secondary cancer, in at least 
one half the cases, affects both organs. 

Parovarian Cysts. 

Cysts of the parovarium may be divided into those which occur 
in the outer series of tubules free at one extremity and known as 
Kobelt's tubes, an inner set of vertical tubules, and lastly a large 
tube running at right angles to the vertical tubes may be occa- 



DISEASES OF THE OVARIES AND TUBES. 571 

sionally traced downward to the vagina. This is Gartner's duct. 
There are two kinds of cysts which arise from the parova- 
rium ; the most frequent are the small pedunculated cysts con- 
nected with Kobelt's tubules, which do not become larger than 
a pea, and consequently have no clinical importance. The most 
important are the sessile, which remain between the layers of the 
mesosalpinx, and as they enlarge burrow into it. In these large 
cysts the Fallopian tube becomes elongated. Small cysts are usually 
transparent ; when they become larger than a cocoanut this appear- 
ance is lost. The fluid is clear, limpid, with a specific gravity of 
1010 and an alkaline reaction. They are distinguished from the 
ovarian cysts, first, by the ease with which the peritoneal coat can 
be stripped off; second, by the ovary being generally found 
attached to the side of the cyst ; third, by the cyst being unilocu- 
lar ; fourth, by the Fallopian tube being stretched over the cyst 
and never communicating with it; fifth, by the specific gravity 
which does not exceed 1010, and may be lower ; and lastly, in 
the same specimens, by the tissue of the mesosalpinx which be- 
comes gradually thickened. These cysts rarely occur before the 
age of sixteen ; they probably form about 10 per cent, of the 
cysts which are subjected to operation. They generally do not 
form adhesions, and rarely suppurate even when tapped. 

Pedicle. — In all varieties of cysts of the ovary or the broad liga- 
ment the presence, absence, or character of the pedicle is of great 
surgical importance. It may be thin, almost membranous ; long 
and narrow, consisting only of the folds of the peritoneum or of 
peritoneum and elongated tube ; or may be broad and thick, 
comprising the entire broad ligament. Its length and thickness 
will depend upon the proximity of the cyst to the uterus. The 
pedicle consists of two parts — the ovarian ligament and the Fallo- 
pian tube. 

The thick pedicle may consist of the broad ligament, hyper- 
trophied and reinforced by muscular tissue from the uterus. When 
there is no pedicle the tumor has developed wholly within the broad 
ligament The tumors of the broad ligament, some dermoids, and 
glandular cysts of the ovary are of this class. 

In the recent removal of cysts of this character the peritoneum 
is separated from the posterior surface of the uterus, while the 
tumor dips dowm upon the left side of the uterus to the roof of 
the vagina, leaving a large membranous cavity. 



672 AN A3IEBICAN TEXT-BOOK OF GYNECOLOGY. 

Etiology. — Ovarian cysts may occur at any age, and are not 
infrequently found in the fetus. Doran describes fetal ovaries which 
contained cysts y2^ to ^ of an inch in diameter, lined with cylindrical 
epithelium and filled with dendritic vegetations. Congenital ovarian 
cysts may be either unilocular or multilocular, unilateral or bilateral. 
Sutton analyzed 60 cases in children under fifteen years of age, 
in which he found 23 dermoid, 16 sarcomata, and 16 simple cysts. 
Thornton has observed cases in which malignant deposits were found 
in the pelvis two or three years after the removal of dermoid cysts, 
which contained soft white growths strongly resembling sarcomata. 
Sutton arranges the group of malignant tumors in children — termed 
by some sarcomata, others carcinomata — under the term oophoromata, 
because they seem to arise from the tissue of the oophoron. Ovarian 
growths occur with greater frequency during the age of sexual activity, 
between the twentieth and fiftieth years. They are comparatively 
rare after sixty, and still more so before puberty. The unmarried 
seem to suffer with greater frequency from these growths. It is 
probable that the cessation of ovulation during pregnancy and lac- 
tation acts as a safeguard against their development, while menstrual 
congestion favors it. Several members of the same family have 
been affected. Each ovary seems to be attacked with equal fre- 
quency. It is estimated that the ordinary cystomata occur bilaterally 
in about 3 per cent., while the malignant, on the other hand, are 
found bilateral in about 75 per cent. Scanzoni has considered 
chlorosis during puberty as a main element in their development. 

Symptoms. — The tumor usually develops insidiously, and may 
attain considerable size before it is discovered, being then, pos- 
sibly, noticed by accident. The earliest symptoms are vesical 
tenesmus, constipation, pain in defecation, and the sensation of 
weight and pressure in the jDelvis. As the tumor increases in size 
general nutrition becomes affected, due to the pressure upon the 
stomach and diaphragm. The patient becomes emaciated, grows 
weak, and suffers from violent abdominal pains, produced pos- 
sibly by a partial peritonitis. (Edema may occur in one or both 
legs and extend to the vulva or lower abdominal walls. The patient 
may have intercurrent febrile attacks, and death may occur from 
exhaustion, or where the tumor fills the pelvis it may produce 
incarceration similar to that resulting from retroversion of the 
pregnant uterus. 

Olshausen divides the subjective symptoms into four classes or 



DISEASES OF THE O VARIES AND TUBES. 573 

groups : First, those produced by violent disease. This may be 
dysmenorrhea, but more frequently early and excessive hemorrhage. 
Excessive menstruation in bilateral tumors and tumors of the broad 
ligament is an early and obstinate symptom, due to the pressure 
upon the pelvic veins. Ergotin and other agents are useless in 
controlling the bleeding. This hemorrhage produces anemia. 
Sterility may result from the disease, partly from physiological 
and partly from mechanical causes. It must not be forgotten, 
however, that conception may take place even when the patient 
is suffering from large tumors. The presence of tumors may 
cause 'pigmentation of the mammary areola and the linea alba, 
painful sensation in the breasts, and even enlargement of these 
organs, with the secretion of milk. Second, symptoms which 
result from depression or weight of the tumor. These are con- 
stant after it has attained to some size. When it is situated in 
the pelvis it may produce tenesmus or strangury by pressure upon 
the neck of the bladder. A large tumor may produce upward 
traction on the bladder and urethra, and cause vesical disturbances, 
and even retention of urine. Defecation is impeded by pressure, 
and becomes painful if the tumor is sensitive. The patient suffers 
from vague, dragging pains, rupture of the rete Malpighii, and con- 
sequent formation of linea albicantes, dilatation of the veins, oedema 
of the abdominal walls, compression of the stomach and intestines, 
and difficult breathing from the pushing up of the diaphragm. 
This pressure necessarily adds an increase of danger to any inflam- 
matory trouble of the lungs. As a result of compression of the 
renal veins and ureters the patient may suffer from albuminuria 
or from suppression of urine by the compression of the ureters. The 
compression of the large abdominal veins causes marked oedema of 
the legs, though this is less frequent than in pregnancy. The tumor 
must be larger than the pregnant uterus to cause these symptoms. 
Third, symptoms of complicating disease. Of these the most fre- 
quent and important are those which arise from attacks of circum- 
scribed peritonitis. These symptoms are usually found in large 
tumors where they extend above the umbilicus. Loss of a portion 
of the superficial epithelium of the tumor necessarily results in its 
adhesion to adjacent parts. The greater the pressure of the tumor 
against neighboring organs, the more readily will the friction pro- 
duce adhesions. This is more likely to occur in the anterior surface 
of the tumor, producing adhesions between the tumor and anterior 



/ 



574 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

parietes. Next in frequency are omental adhesions, and then follow 
adhesions to the intestine, bladder, uterus, spleen, stomach, liver, and 
floor of the pelvis. These produce attacks of pain, lasting for days 
or weeks, with tenderness of the parts affected. Other complicating 
symptoms are pressure upon the intestines, producing intestinal 
irritation or obstruction ; intestinal occlusion from pressure upon 
the rectum, or occasionally, after puncture, from twisting of the 
intestines where they have been adherent. Fourth, symptoms on 
the part of the general condition of the patient. The general 
health of the patient usually remains good until the digestion is 
impaired by pressure upon the stomach. Then marasmus occurs, 
appetite is lost, the tongue becomes dry, there is persistent vomiting, 
and the features become sunken ; the expression of the face with the 
enormously distended abdomen presents symptoms which usually 
indicate the presence of the disease. 

Before taking up the study of the objective symptoms or physical 
signs of ovarian cysts we will enter upon the consideration of com- 
plications arising from changes in the cyst itself. These are — first, 
hemorrhages ; second, suppuration and gangrene of the cyst ; third, 
adhesions ; fourth, torsion of the pedicle ; fifth, rupture ; sixth, 
metastatic deposits. 

Hemorrhage into the cyst occurs from a variety of causes. It 
may take place in papillomatous cysts if the superficial vessels are 
greatly distended, or from the cyst-wall where the veins have rup- 
tured by dilatation. The most frequent cause is from torsion of the 
pedicle. Moderate torsion interferes with the return of the blood 
through the veins, while the arterial circulation may still be main- 
tained. It may take place from puncture through injury to a large 
vessel in the cyst- wall. Hemorrhage usually occurs slowly and in 
small quantities, and consequently is of no prognostic significance. 
Where copious, as in acute torsion of the pedicle or where large ves- 
sels are punctured, it may seriously threaten life and produce pro- 
found and dangerous collapse. 

Inflammation a7id suppuration of a tumor may be produced by a 
number of conditions. Thus they may result from infection through 
the intestinal canal, urinary bladder. Fallopian tube, or the admis- 
sion of air in tapping. This may affect small as well as large cysts. 
Dermoids are especially prone to suppuration. The most common 
avenne of infection is through the Fallopian tube. Adhesions 
generally take place in the immediate neighborhood of its ostium, 



DISEASES OF THE OVARIES AND TUBES, 575 

affording opportunity for inflammation to extend over the cyst, 
thus causing adhesions to the omentum, intestines, and parietal 
peritoneum. The intestines are sometimes the source of infection 
through adhesions of the small intestine or the rectum to the cyst- 
wall. As the adherent piece of intestine becomes compressed by the 
tumor, its wall becomes thinned, allowing the diffusion of intestinal 
gases. It may become so thin as to permit the gas to pass directly 
into the cavity of the cyst, causing putrefaction and converting it 
into a huge abscess ; in some cases the inflammation has originated 
in an appendicitis. It was formerly supposed to be due invariably 
to the accidental admission of air through tapping, but, as we have 
seen, it may occur independently of that cause. In acute cases, 
where inflammation results in early adhesions to the surrounding 
structures and viscera, marked symptoms arise, and unless the pus 
finds exit the patient dies. When exit is afforded, the patient may 
be worn out by the prolonged discharge. 

Symptoms are pain, tenderness over the region of the tumor, 
rapid and feeble pulse, great emaciation and exhaustion, with a tem- 
perature of 102° in the morning, 103-106° in the evening, or where 
the patients have become greatly exhausted the temperature may 
fall as low as 95°, especially when the pus is in considerable quan- 
tity. The urine may be found to contain albumen, and the cyst, 
through its communication with the intestine, may contain gas, pro- 
ducing a tympanitic note. Suppurating dermoids are not of infre- 
quent occurrence, often cause extensive adhesions, and burst into 
the peritoneum, rectum, bladder, vagina, or even through the 
abdominal wall. Communication of such a tumor with the blad- 
der excites profound distress. Portions of bone, teeth, locks of 
hair, or sloughs become packed in the urethra, and cause retention 
of urine and the occurrence of cystitis. Fragments remaining in 
the bladder are covered with phosphatic deposits and form a nucleus 
for the formation of calculi. 

Adhesions, when extensive, are always a source of additional 
anxiety. When they have existed for some time between the intes- 
tines, colon, and cyst-wall, forming broad, fibrous bands of close 
adhesions, the task of removal is an exceedingly tedious, and occa- 
sionally an impossible one. The adhesions result from inflamma- 
tion of the surface of the peritoneum, the exudation from which is 
slowly converted into fibrous tissue. If the parts remain in con- 
tact during the formation of the adhesions, what is known as a ses- 



576 AN A3IEBICAN TEXT-BOOK OF GYNECOLOGY. 

sile adhesion is produced. If movement is kept up, the bands of 
adhesions are elongated, forming broad or narrow bands. The cyst 
may present a shaggy appearance from extensive adhesions. The 
older adhesions contain blood-vessels, which are of large size when 
the intestine or omentum is involved. The vessels thus formed are 
frequently so large that when a pedicle has been destroyed by tor- 
sion the tumor is still nourished by its new relation. The most 
dangerous adhesions are those in the pelvis, on account of their 
intimate relation with the iliac arteries and veins, and it is in 
many cases exceedingly difficult, if not impossible, to determine 
their presence until operation is resorted to. In separating pel- 
vic adhesions in a patient sixty-three years old, some years ago, 
using but very slight force, a large vein was torn open, and the 
patient lost so much blood before the hemorrhage could be arrested 
that she died a few hours later from shock. 

Axial rotation, or torsion of the pedicle, occurs in probably 10 
per cent, of the cases. It has been attributed to a variety of causes, 
as the alternate distension and evacuation of the bladder, passage 
of feces through the rectum, sudden movements, unusual exercise, 
the occurrence of pregnancy, delivery of the patient, and so on. It 
is more likely to occur in double ovarian tumor. It is possibly also 
induced by changes of position of the patient. The rotation varies 
from half a circle to as many as ten or twelve complete twists. The 
rotation takes place from right to left or left to right with about 
equal frequency, dependent, possibly, upon the side on which the 
tumor is situated. The tendency is to rotate toward the median 
line rather than from it. The effect on the circulation depends 
upon the amount of torsion as well as upon the thickness of the 
pedicle. A long, thin pedicle is the most frequently twisted. The 
veins are the first to suffer from the twisting, causing acute enlarge- 
ment of the cyst from extravasation of blood into its cavity. The 
veins may rupture and hemorrhage take place into the cavity of 
the cyst — hemorrhage so profuse as to produce acute anemia and 
even death. On opening the abdomen of such a patient, the cyst 
will be found dark-colored, more particularly near the pedicle. 
The fluid in the cavity may be chocolate or dark- red in color. 
The most frequent effect of torsion is thrombosis of the vessels, 
extravasation of blood, and necrosis. Necrosis is followed by 
decomposition and putrefaction of the dead tissues. 

Torsion may be acute or chronic. In the latter the changes are 



DISEASES OF THE OVABIES AND TUBES, 577 

slow. Acute torsion is generally seen in small tumors. The larger 
the tumor, the more profound is the constitutional effect. Symptoms 
of acute rotation are frequently so marked as to leave no question 
as to the condition. When the patient complains of sudden and vio- 
lent pain in the abdomen, vomiting, and the presence of acute swell- 
ing, one should suspect its occurrence. This is still more probable 
if the woman be pregnant. The rupture of the gravid Fallopian 
tube may induce symptoms which would be mistaken for torsion. 
The indications for prompt relief, however, are the same in each 
case. The symptoms in the chronic variety are not so marked. 
The patients complain of a dull, sudden abdominal pain, and still 
maintain good health, with a tumor, however, which more rapidly 
increases in size. In these cases the prognosis is good if the adhe- 
sions are few or slight. 

Rupture of the Cyst. — Rupture of the cyst may be sudden, as the 
result of a fall, blow, or injury, or gradual from change in the cyst- 
wall. In the latter the cyst becomes thinner, more particularly in 
the proliferating cystomata. In such growths, as they increase in 
size, the accumulation presses upon their walls, which become 
thinned, until they give way at some point or until the papillary 
growths project through the thinned walls. Rupture of the cyst 
may take place into adherent viscera, and more generally occurs 
into the peritoneal cavity. The result of such a lesion is depend- 
ent somewhat upon the quantity and quality of the fluid contained. 
In the unilocular cysts the fluid is most innocuous, and may fre- 
quently produce no abnormal symptoms other than an increased 
diuresis. The patient probably passes several gallons of water in 
twenty-four hours. The abdomen, so prominent from the tumor, 
becomes flattened, flabby, and possibly the remnant of the cyst may 
be recognized upon palpation. Rarely the cyst-wall may shrivel 
and a radical cure be effected. In the multilocular cysts, and par- 
ticularly the dermoids, rupture into the j)eritoneal cavity may be fol- 
lowed by infection, a rapidly developing grave peritonitis, and 
finally death. This termination is particularly probable, not only 
in dermoids, but in those containing colloid material, or particularly 
where pus is present in the cyst. In dermoids the decomposing fat 
is eminently productive of inflammation. Death may be very rapid 
as a result of the shock or the absorption of the deleterious mate- 
rial. In papillary cystomata rupture results in the infection of the 
peritoneal cavity and the formation of growths upon its surface, in 

3V 



578 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

some cases studding the entire peritoneum. Kupture is determined 
by disappearance of the tumor, diminution in its size, demonstration 
of free fluid in the abdomen, peritonitis, collapse, and diaphoresis 
or diuresis. Rupture into the peritoneal cavity may be mistaken 
for torsion ; when into the intestines, it is recognized by the evac- 
uation of colloid masses or chocolate-colored fluid ; where the open- 
ing is high up, violent watery diarrhea may occur; when into the 
bladder, by vesical tenesmus and dysuria ; or where dermoid, it is 
recognized by the peculiar contents of the cyst. External rupture 
is usually determined without difiiculty. When pus or ichorous 
material alone are discharged, it is sometimes difiicult to determine 
whether it proceeds from a cyst or an abscess in the walls. 

Metastasis occurs in cancer of the ovary extending to the perito- 
neum, causing ascites, or secondary nodules may be found in remote 
organs, as the liver, spleen, and, rarely, the kidney. In papillary 
growths the peritoneum becomes infected, and through the peristal- 
tic action may infect the entire abdomen. So extensive is the infec- 
tion, and so prone to occur after the removal of these tumors, that 
it has been sometimes questioned whether papillary tumors did not 
belong to the malignant class. Their structure, formation, and the 
fact that they are not always absolutely fatal renders this improb- 
able. The dermoid element has also been found implanted in the 
peritoneal cavity. Small tufts, covered with hair, have been noticed 
growing from the surface of the peritoneum of the intestine. A 
similar covering with colloid material has been found in multiloc- 
ular cysts. 

In a case operated upon by the writer some years ago the entire 
peritoneal cavity was studded with a thick colloid material which 
could not be entirely scraped ofl! 

Other complications of ovarian cyst are — 

1. Ascites. — A small amount of ascitic fluid may be present with 
many cysts, but a large quantity is rare so long as the tumor retains 
its normal condition. Changes in its structure, especially if of 
malignant character, are prone to an increase of free peritoneal 
fluid. Ascitic collections complicating ovarian cyst are said to' be 
much richer in solids, containing from two to two and a quarter 
ounces, instead of six drachms. In malignant disease the fluid 
becomes darker, like prune-juice. 

Large ascitic accumulations result from rupture of colloid or, 
particularly, of papillary cysts. Solid growths are generally attended 



DISEASES OF THE OVARIES AND TUBES. 579 

with ascites. The presence of fluid in the peritoneal cavity is by 
no means an indication of malignancy, as it occurs in fibromata 
as well as in sarcomata and carcinomata. In the former, probably, 
it is due partly to the irritation of the peritoneal epithelium and 
partly to pressure upon the vessels. 

2. Intestinal obstruction or strangulation from 'pressure of the cyst 
or adhesions to its surface, or torsion or volvulus from such adhe- 
sions takes place when the tumor has been reduced by puncture. The 
intestine may become occluded by extension of malignant disease. 

Course, Duration, and Termination. — The rapidity of the 
growth of an ovarian tumor depends somewhat upon its character. 
Those of slovi^ growth are usually cysts of the broad ligament, 
fibromatous tumors, and the fibro-myomata of the ovary. Prolifer- 
ating cysts, whether glandular or papillary, grow more rapidly. 
The latter grow so rapidly that considerable increase in size may 
be noticed in ten days. The intra-ligamentary cysts of papillary 
origin are generally of slow growth. At the end of years they 
may not be larger than a child's head. Such patients suffer from 
profuse menstruation, due to the pressure upon the veins obstruct- 
ing the return circulation. In the later stages ascites is developed, 
which rapidly returns after tapping. It is difficult to determine 
the duration of the disease where undisturbed. In 60 to 70 per 
cent, at least of the proliferating cystomata the patient dies within 
three years after the advent of the first symptoms, and another 10 per 
cent, die within four years. The slow-growing papillary cystomata 
generally cause the death of the patient from marasmus, but the 
average duration of the disease is longer than in the proliferating 
variety. Such a patient has been punctured one hundred and five 
times in seven years, with the removal of twenty-five to forty 
pounds of fluid at each operation. The proliferating cysts may ' 
remain unchanged even for years. Patients suffering with ovarian 
cysts may heal spontaneously or pass into a condition which is 
equivalent to recovery. Spontaneous recovery generally occurs 
from rupture of the cysts. This favorable result occurs more par- 
ticularly in simple cysts, but rarely, if at all, in the proliferating. 

Torsion of the pedicle, or axial rotation, may bring about 
recovery in colloid tumors. Such a termination, however, is rare, 
and the recovery is not absolute, as there usually can be found a 
mass in the former position of the tumor. Spontaneous recovery, 
indeed, is rare, even in unilocular cysts, and in the proliferating 



580 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

cystomata is never looked for. Unless such patients are subjected 
promptly to surgical treatment, death occurs in the majority of 
cases from exhaustion, as a result of anorexia, impaired digestion, 
sleeplessness, and interfered respiration and circulation. Patients 
may suffer from bed-sores or intercurrent disease, which may 
rapidly prove fatal. Death is occasioned in other cases from peri- 
tonitis after torsion of the pedicle, rupture, or metastasis upon the 
peritoneum. Other fatal conditions may be intestinal occlusion 
and embolism of the pulmonary artery. The presence of ascites 
in considerable quantity is generally an unfavorable omen. Another 
cause of fatal result may be suppuration from puncture. This re- 
sult was formerly very frequent. The presence of ascites must be 
considered an unfavorable symptom when it is associated with papil- 
lary growths or rupture of a glandular tumor. A tumor which has 
not been long in existence and which undergoes sudden develop- 
ment, attended with rapid emaciation and cachexia, multiple adhe- 
sions, especially in the pelvis, and oedema of the lower limbs and 
the abdominal walls, with peritonitic complication, should indicate 
a malignant onset. In such cases the outlook for a successful ope- 
ration is bad, although operation should be done wherever there is 
the least chance for success. 

The PHYSICAL SIGNS of the patient are determined by inspection, 
palpation, percussion, and auscultation. In the examination of the 
patient she should be placed upon a bed or couch, the limbs drawn 
up, clothing loosened, all constricting bands removed, so that the 
abdomen can be thoroughly and completely exposed. It is well that 
the patient should have been previously directed to have the bowel 
and bladder emptied. After covering the lower extremities with a 
sheet, and bringing it over the lower part of the abdomen so as to 
avoid exposure of the genitalia, the abdomen is bared. The first 
general procedure in examination is that of inspection. By inspec- 
tion we are enabled to determine the size of the growth, the height 
to which it rises from the abdomen, its position, whether symmetrical 
or one-sided, the smoothness of its outline, whether spherical or 
larger from side to side, the appearance of the skin, presenting the 
linea albicantes, darkened line down the centre — the linea nigra, and 
discolorations of the skin indicating the application of counter-irri- 
tants and the presence of pre-existing inflammatory troubles. An 
irregular nodular appearance of the tumor would indicate that if 
cystic it consisted of a number of cysts, causing irregularity of the 



DISEA8ES OF THE OVABIES AND TUBES. 581 

surface. The dark line is generally considered a symptom of preg- 
nancy, but when it occurs it is permanent in duration, so that it is 
only in the first pregnancy that it is of value. It should not be 
forgotten, however, that this increase of the local pigment occurs in 
women who suffer from ovarian cyst or uterine fibroids; the pres- 
ence of linea albicantes has no significance as regards the question 
of pregnancy. They arise from any distension of the abdomen 
sufficient to cause rupture of the skin, and hence are found not 
only in pregnancy, but in ovarian cyst, ascites, and other conditions 
which are likely to cause abdominal enlargement, and may be 
entirely absent in women who have borne children. 

Palpation i§ practised by placing the hand over the abdomen, in 
cold weather the hands having been previously warmed. The 
abdominal cavity is carefully explored, the condition of the various 
organs investigated, and any enlargement of the abdomen, presence 
of a cyst or tumor, can generally be readily recognized. Palpation 
is practised by placing the hands now upon opposite sides of the 
abdomen and then close together, going over one portion after 
another, so determining the size, consistency, resistance, and regu- 
larity of the growths, the presence of outgrowths or nodules, and 
the sensation of crepitation or of friction. Placing the hand upon 
one side and striking gently with the other will elicit fluctuation, 
particularly when we are dealing with a large unilocular cyst. In 
multilocular growths the fluctuation wave would be shorter or may 
be entirely absent. 

Percussion is of special value in determining the outline or ex- 
tent of growths, their relation to the abdominal viscera, and their 
determination from other forms of abdominal distension. It affords 
an absolute means of differentiation of growths from distensions of 
the abdomen by free fluid or accumulations of gas. 

Auscultation gives but slight information. It is of service 
in differential diagnosis, more particularly in its negative results. 

Diagnosis. — The diagnosis of ovarian tumors may be divided 
into two divisions : first, the determination of such growths when 
small and situated in the pelvis ; second, when large, filling the 
greater part of, or the entire, abdominal cavity. 

The physical signs vary according to the size and position. In 
the former stage the tumor is entirely within the pelvis and its posi- 
tion varies. It may retain the normal situation, and as it increases 
in size may encroach upon the general abdominal cavity. Tumors 



582 



AN AMEBIC AW TEXT-BOOK OF GYNECOLOGY. 



when as large as a hen's egg, however, generally fall downward and 
backward into Douglas's pouch immediately behind the uterus. In 
rare cases they may be found in front or to one side. The ovary, but 
slightly enlarged, may retain its normal position. Its relation to 
the corresponding side of the uterus affords but little difficulty in 
determining its character by conjoined manipulation. Where its 
growth has been associated with peritonitic inflammation, it may be 
more difficult to determine its true character. Small tumors are 
usually firm to the feel, for the reason that they are too small to 
produce an elastic consistency. In a large tumor situated behind 
the uterus the diagnosis is determined by the circumscribed cha- 
racter of the growth. Elasticity is a valuable sign, which is gen- 
erally absent in proliferating cystomata, and even in single cysts, 
and particularly dermoids, which afford a solid sensation to the 



Fig. 346. 




Distension of the Abdomen by an Ovarian Tumor. 

touch. If we are unable to determine or separate the tumor from 
the uterus, and consequently to determine its pedunculation, this 
can be ascertained by Hegar's method, which consists in placing 
the patient upon her back, seizing the uterus by a pair of volsella 
forceps, and strongly dragging it down ; at the same time we en- 
deavor to feel the lateral borders of the uterus as far as the fundus 



DISEASES OF THE O VARIES AND TUBES. 583 

with one or two fingers in the rectum, or we push the uterus down- 
ward and backward by means of the outer exploring hand, and 
thus outline its relations. When the tumor is not too large it can 
generally be outlined with the finger in the rectum and the hand 
over the abdomen. The greatest difiiculty is experienced in those 
cases in which the tumor is adherent in the pelvis and surrounded 
by exudation or is incarcerated. Tumors which are situated en- 
tirely within the broad ligament, and formed unilaterally or bilat- 
erally or in close apposition to the uterus, are less spherical and cir- 
cumscribed, and less movable from the start. Small growths must 
be diagnosed from fibroids and tumors caused by disease of the 
tubes, particularly hydro-, pyo-, and hematosalpinx. The more 
acute history, marked tenderness, evidence of inflammatory exu- 
dation, thickening and matting together of the pelvic tissues, and 
increased pain, would eliminate pyosalpinx. In hydrosalpinx the 
tumor may be movable, present a sensation of elasticity or fluctua- 
tion, but it is oblong or gourd-shaped rather than spherical. It is 
closely attached to the uterus and presents a history of previous in- 
flammation. Hematosalpinx is at first soft, and then becomes hard 
and dense from coagulation of the blood. It is situated to one side 
of the pelvis rather than posterior to the uterus. 

Large or Abdominal Cysts. 

In a woman suflering from a large ovarian cyst the abdomen will 
be found distended more particularly at its lower part, quite promi- 
nent, and rising abruptly from the pubes. As the patient lies upon 
her back with the abdomen exposed, it will be seen to be sharply 
and definitely outlined, and generally symmetrically developed ; if 
any difference, a little more prominent on the right side. Palpa- 
tion may determine its outline, extent, and size. If there is a 
large single cyst, the surface will be smooth and regular, while in 
multilocular cysts it may present projections and irregularities. If 
made up of a number of small cysts, it will present a much more 
marked resistance, although there is still a sensation of elasticity. 
The tumor may be moved from side to side or pushed upward and 
downward. Percussion discloses dullness over the entire surface 
of the tumor, with resonance above and possibly resonance in the 
flank upon one side. The resonance in this region is supposed to 
indicate that the tumor has developed from the opposite side or 
ovary, and as it increased in size has pushed the intestines upward 



584 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

and to the unaffected side. We cannot, however, with certainty 
determine in this way the ovary from which the tumor has arisen, 
as when the growth has increased in size it is likely to become 
prolapsed into Douglas's pouch and develop from there ; conse- 
quently this does not afford a positive indication as to the source 
of orio'in. 

Considering the conditions with which ovarian cyst may be con- 
founded, it is well to begin with pregnancy, from its greater frequency 
and importance. Vice versa, it may seem unreasonable that preg- 
nancy should be mistaken for an ovarian cyst, but there are a number 
of cases upon record in which the abdomen has been opened to find 
the distension caused by a pregnant uterus. In order to arrive ?t a 
correct diagnosis, we need to carefully analyze the symptoms of the 
two conditions. In this we consider the history of the case. In 
pregnancy the enlargement of the abdomen is more rapid, and is 
generally attended with suppression of the menstruation, the sym- 
pathetic symptoms, nausea, vomiting, disturbed appetite, with a 
healthy appearance of the individual. Suppression of menstrua- 
tion is not a constant symptom of pregnancy, as there are women 
who continue to menstruate during the entire period of pregnancy. 
It may be associated with ovarian cyst, particularly where both 
ovaries are completely degenerated. Error is most likely to occur, 
in early pregnancy, in the unmarried. In these cases the physician 
should carefully avoid announcing a diagnosis until a careful exam- 
ination has been made, and even then should not be too hasty. If 
there is any doubt, he should defer expressing an opinion, and have 
the patient undergo an examination a few weeks later. The changes 
which occur will generally be sufficient to enable him to express a 
definite opinion. In pregnancy there is generally an absence of 
fluctuation. The same symptom may be absent in ovarian cyst with 
thick viscid contents, or in the areolar or glandular varieties made 
up of a large number of small cysts. Later, fetal movements and 
parts of the fetus may be distinguished, and the fetal heart-sounds 
recognized. The latter symptom is one which is pathognomonic of 
pregnancy. Heart-sounds, however, are not always heard, owing to 
the position of the fetus and the large quantity of fluid or possible 
fetal death. Conjoined examination through the vagina or rectum 
should be a part of the procedure. By it we are enabled to deter- 
mine the association of the abdominal distension with the increased 
size of the uterus. Gestation in one horn of a bicornate uterus may 



DISEASES OF THE OVARIES AND TUBES. 585 

render diagnosis difficult. Careful examination by the vagina and 
rectum will show the association of the enlargement with the uterus, 
the other cornu possibly remaining small. Where there is the least 
suspicion of pregnancy the introduction of the uterine sound should 
be absolutely avoided. 

Hydramnios. — Cases in which the liquor amnii exceeds two 
quarts have been mistaken for ovarian tumor. Large accumulations 
within the walls of the uterus give rise to fluctuation, the abdominal 
walls will be greatly distended, glistening, and the patient will suffer 
from all the discomfort arisino* from a marked abdominal distension 
from ascites or ovarian cyst. This condition generally comes on 
suddenly, and takes place about the sixth or seventh month of preg- 
nancy, which prior to its occurrence has run a normal course. On 
examination the uterus will be found distended, possibly the cervix 
obliterated, the os open, covered with a dense membrane, and by 
manipulation we may be able to distinguish the symptom of bal- 
lottement ; rupture of the membrane results in the discharge of a 
quantity of water and the emptying of the uterus. The existence 
of ovarian cyst of one or both ovaries does not necessarily indicate 
the non-existence of pregnancy, as so long as any ovarian stroma 
remains unaffected, ovulation and conception may occur. The 
increased quantity of blood that is sent into the pelvis during the 
development of pregnancy may increase the rapidity of develop- 
ment of an ovarian cyst. The enlargement of the abdomen may 
be so marked as to indicate the necessity for interference with the 
process in order to prolong the patient's life. Careful examination 
will disclose the enlarged uterus either in front of or behind the 
ovarian cyst. In some cases the ovarian cyst may be situated in the 
pelvis and obstruct the vagina, rendering it difficult to reach the 
cervix. In the later months of pregnancy such cysts may be tapped, 
enabling the individual to go over until the completion of gestation, 
or, if found early, ovariotomy may be performed. The existence of 
pregnancy does not seem to influence its mortality. Morbid collec- 
tions within the uterus may be physo-, hydro-, or hematometra. 
Physometra is a collection of gases within the uterus, the result of 
decomposition, and is a very rare condition. Hydrometra is a col- 
lection of water in the organ, which is more likely to take place in 
women of advanced age, due to the retention of the secretions from 
obliteration of the canal Hematometra may result from occlusion 
of the cervix or vagina, with retention of menstrual discharges. 



586 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

It is more likely to occur near puberty. Examination by vagina 
or rectum is usually sufficient to demonstrate the cause. Other 
growths within the uterus which have led to difficulty in diagnosis 
are myomata or fibro-myomata. These growths are rare before the 
twenty-fifth year ; indeed, not common before the thirtieth. They 
are more likely to be confounded with ovarian tumors on account 
of the very great size to which they attain, filling up the entire 
abdominal cavity and presenting a tumor larger than the pregnant 
uterus at full term. These growths are usually of slow develop- 
ment, irregular in outline, present a firm and marked resistance and 
the absence of fluctuation. They may cause no disturbance of the 
menstrual function, as in the subperitoneal fibroids, or marked 
menorrhagia in the submucous. Vaginal examination discloses the 
close association of the tumor with the uterus. Generally move- 
ment of the tumor will cause movement of the cervix. Where the 
tumor is but connected with the uterus by a long pedicle, it may be 
more difficult to determine its character. This may be accomplished 
by having the tumor, through the abdominal walls, draw^n up by 
an assistant, while the cervix is drawn down by a volsellum in the 
hand of the examiner, who introduces the finger of the other hand 
into the rectum, and thus definitely determines the association of 
the mass with the uterus. If it can be entirely separated from that 
organ, it is evident the growth is ovarian. Auscultation usually 
discloses a blowing sound due to the coursing of blood through the 
large uterine sinuses — a condition which is absent in ovarian cysts. 
The conditions which are most difficult to determine are those in 
which a fibroid with long pedicle is oedematous, giving a sensation 
of elasticity, or an ovarian cyst with thick, viscid contents, or those 
cases of fibroid growth which have undergone cystic degeneration. 
The methods we have already mentioned of determining whether 
the growth is a part of the uterus may be exercised, and in cases 
of doubt it may be necessary to resort to exploratory incision. 

Ascites. — There is generally little difficulty in arriving at a cor- 
rect diagnosis in cases of uncomplicated ovarian cyst. Unilocular 
ovarian cysts, probably more frequently than any others, are con- 
founded with ascites. It may be avoided by keeping in mind that in 
ascites, if the patient lies upon her back, the abdomen is likely to 
be flattened, broader from side to side — that there is less resistance, 
and upon palpation the abdominal wall can be depressed to a greater 
degree, displacing the free fluid. Upon percussion in ascites there 



DISEASES OF THE OVARIES AND TUBES. 587 

is a zone of resonance at the summit of the distension, due to the 
intestines filled with gas floating to the surface, while there is dull- 
ness in the flank and over the sides. In ovarian cyst there is dull- 
ness over the surface of the distension, resonance above it and over 
one flank. In ascites the level of the fluid changes with the change 
of position, consequently the resonance changes ; in ovarian cyst it 
is unchanged. Very marked abdominal distension may afford an 
element of uncertainty in the fact that the distension is so great 
that the mesentery is too short to permit the intestines to come in 
contact with the abdominal surface. In such cases depressing the 
abdominal walls, thus displacing the intervening layer of fluid, may 
afford resonance, w^hile superficial percussion is dull. Owing to a 
communication with the intestines gas may pass into the ovarian 
cyst, causing resonance over its surface. In these cases we will have 
to depend upon the resistance of the cyst to determine its presence. 
In cases of ascites, also, the history will be of advantage, as afford- 
ing information of renal, cardiac, and hepatic disease. In cases of 
inflammatory ascites or ascites from tubercular peritonitis the dia- 
gnosis may be difficult, and only determined by incision. Ascites 
may complicate an ovarian cyst ; thus by depression a layer of fluid 
may be displaced, bringing the hand in contact with the tumor 
within. The amount of resistance will determine whether the 
tumor is solid or cystic. The presence of ascites is generally an 
indication of the malignancy of the growth. The more marked 
the ascites, the greater the probability of malignancy. The only 
exception to this rule is in fibroids of the ovary which may give 
rise to an ascites, probably from irritation of the peritoneum or 
obstruction to the return circulation. The uterus will be found 
freely movable in ascites, while in ovarian cysts it will be displaced 
either downward and backward or upward and forward. In ascites 
from papillary cysts the uterus presents on either side a dense 
thickened mass which should cause a suspicion of its true character. 
Phantom Turn.or. — Phantom tumor is a condition in which there 
is an apparent tumor due to distension by gas. This may in some 
cases attain to considerable size, and when associated with the illusion 
of supposed pregnancy is known as pseudo-cyesis. It is more likely 
to occur in nervous sterile women. The form just spoken of occurs 
in cases of illicit intercourse, or in young individuals in whom there 
is a fear of pregnancy, or in older in whom there is a morbid desire 
to have children. Such patients will experience the fetal move- 



688 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

ments and all the ordinary sensations of pregnancy. It is likely 
to occur at or near the climacteric, and is generally associated with 
a large increase of adipose tissue. Percussion over the abdomen is 
sufficient to disclose the fact that the apparent tumor is filled with 
gas. Palpation will generally elicit the absence of any tumor, or, 
if the swelling or distension remains permanent under pressure, it 
may be entirely removed by placing the patient under the influence 
of an anesthetic. 

Uterine Myomata complicating Ovarian Cyst. 

The presence of a cyst of the ovary and a fibroid tumor of the 
uterus in the same patient is not infrequent. Where the ovarian 
cyst is large and situated in front of the uterine tumor, the diagnosis 
may be difficult, and only determined after puncture of the cyst or 
abdominal section. The author recently made a diagnosis of this 
condition in a patient with the following history : A woman aet. 33 
years, married, had been suffering with abdominal enlargement for 
nearly a year, which for the last four months had increased more 
rapidly. She had been suffering from irregular hemorrhage ; w^as 
pale and emaciated; she complained of severe pain over the abdo- 
men, increased by exertion. The abdomen was distended about the 
size of a six months' pregnancy ; upon the right side, a little below 
the level of the umbilicus, was a hard, firm growth, apparently 
closely associated with a tumor upon the left side which extended 
above the umbilicus. The left tumor was more elastic and apparently 
contained fluid. Moving the mass upon the right caused the cervix 
to move, while movement of the left tumor apparently had no influ- 
ence upon it. The diagnosis was, right side, myoma; left side, 
probably ovarian cyst made up of small cysts. Upon preparation 
for operation she was found to present a softened, dilated cervix, a 
bloody discharge, and within the uterus a fetus which gave evidence 
of having been two weeks dead. 

Obesity. — A large pendulous abdomen from accumulation of fat 
within its walls or fat in the omentum may be mistaken for an 
ovarian cyst. The history of development, the general distribution 
of adipose over other parts of the body, while with ovarian cysts 
there is loss of adipose or emaciation, affords the diagnosis. The 
thickness of the abdominal walls may be estimated by pinching up 
a fold of the skin and subcutaneous tissue. 

Ventral Hernia. — In two cases the author has been called to 



DISEASES OF THE OVABIES AND TUBES. 



589 



see patients suffering from supposed ovarian cysts, when the con- 
dition was due to separation of the recti muscles and protrusion 
of the intestines covered only by skin and peritoneum. Palpa- 
tion of the intestinal coils and resonant percussion should have ex- 
cluded the diagnosis of a cyst. 

Desmoid Tumors. — These tumors originate in the fascia or deeper 



Fig. 347. 




Fatty Abdominal Wall, Simulating Ovarian Cyst. 

layers of the muscles. They are firm and resisting, are movable 
within the abdominal walls, above the surface of which they project 
to a marked degree. Marginal or rectal examination aids in exclud- 
ing them from a pelvic origin. 

Tympanitis. — Abdominal distension, as in phantom tumors, 
whether local or general, is characterized by resonance. The latter 
is associated with symptoms of inflammation ; the former occurs in 
nervous, hysterical individuals. 

Fecal Tumors. — An accumulation of feces is sometimes called a 
fecal tumor. It generally takes place in the colon. If it occurs in 



690 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the transverse colon, that organ may be displaced downward by its 
weight, and rest over the lower part of the abdomen. Such accumu- 
lations are sometimes quite extensive. They are distinguished, how- 
ever, by the length of the tumor, the peculiar sensation to the touch, 
the fact that it retains the imprint of the finger, and that it is en- 
tirely removed by free purgation and copious enemata. 

Distended Bladder. — An over-distended bladder forms a tumor 
in the lower part of the abdomen, which fluctuates, is sensitive to 
pressure, and may be mistaken for a cyst. The precaution should 
alw^ays be taken to empty the bladder as a preliminary step to ex- 
amination. It will of course thus be eliminated. In cases of preg- 
nancy or fibroid tumor impacted in the pelvis, or even in impacted 
ovarian cysts, we may have retention resulting, and difficulty in 
the introduction of a catheter. In such cases it may be necessary 
to use a male catheter. 

Cystic tumors, which may be mistaken for those of the ovary, are 
hydatid cysts of the liver and spleen, and cysts of the omentum, 
mesentery, pancreas, and kidney. Instead of cysts of the kidney, 
we may have the entire structure of the organ dilated, giving rise 
to a hydro- or a pyo-nephrosis. Hepatic cysts or dilatations of the 
gall-bladder are only mistaken for ovarian cysts when they are very 
large, filling up the abdominal cavity or by their weight dragging 
down toward the pelvis. When small they are found situated in 
the upper part of the abdomen to the right side. The diagnosis is 
usually determined by the percussion resonance being situated to 
the opposite side and the lower part of the abdomen, while there 
is dullness above. On vaginal examination the position of the 
uterus will be disclosed ; also possibly the ovaries enlarged on either 
side of it may be recognized. In the hydatid cyst crepitation 
elicited by placing the hand over the cyst, and making pressure, 
will aid in determining its character. This is still further con- 
firmed by finding upon microscopical examination of some of the 
fluid withdrawn for that purpose, booklets and spurs of the echino- 
cocci. Tumors of the spleen are situated on the right side of the 
abdomen, and extend downward toward the pelvis, not infrequently 
enlarging across the abdomen. Mesenteric and omental cysts attain 
a considerable size, and often present great difficulties in diagnosis. 
Manipulation may, however, disclose the ab^nce of attachment to 
the pelvic organs, and in this way afibrd a sus23icion of their true 
character. The mesenteric cysts usually develop behind the peri- 



DISEASES OF THE OVARIES AND TUBES. 591 

toneum, and are consequently retro-peritoneal cysts. They may 
be situated to one side of the abdomen or in the median line, and 
usually do not dip down into the pelvis. Fluctuation is indis- 
tinct, and may be associated with resonance from the overlying 
intestine. Renal cysts in their origin develop from one side of the 
abdomen, are usually more or less fixed, and, increasing in size, may 
be pushed or displaced downward, in some cases occupying the 
anterior surface of the sacrum. An important aid in the diagnosis 
of these tumors is their mobility. Retro-peritoneal cysts some- 
times develop in the pelvis, filling it up and rising upward into the 
abdominal cavity. Such tumors will usually be found closely asso- 
ciated with the uterus and difiicult to separate from it ; the uterus 
will be lifted up by them, the fundus felt in front of the tumor, 
above the symphysis ; there will be a displacement generally of the 
rectum more to the left side, or it may run over the anterior surface 
of the tumor. These tumors are more or less resisting, presenting 
a sensation of elasticity rather than fluctuation. They generally 
are rapid in growth and of malignant character, more particularly 
the sarcomatous variety. 

Where our examination satisfies us that we have to deal with an 
ovarian cyst, it still becomes a question of considerable importance 
to determine its character, whether single, multilocular, or der- 
moid. Multilocular cysts are usually of more rapid growth. 
They present a sensation of greater resistance than the unilocu- 
lar, with a less distended wave of fluctuation. In the unilocular 
cyst the wave of fluctuation can be distinctly felt from one side 
of the abdomen to the other. In the multilocular, as the cyst is 
divided up into a number of smaller cysts, the wave of fluctua- 
tion must necessarily be shorter, and if the cysts are sufficiently 
small no fluctuation will be distinguished. These cases are some- 
times exceedingly difficult to determine from the oedematous fibroid, 
and it is only by careful manual examination, by which the associ- 
ation of the latter with the uterus is determined, that we are able to 
arrive at a diagnosis, and in some cases only an abdominal incision 
will afford us a correct knowledge. 

A case came under observation a year ago in which to the right 
of the cervix was found a mass, somewhat hard and resisting, which 
was felt to be continuous with the cervix. Above this was a con- 
siderably larger mass, soft and elastic, and between this and what 
we had supposed to be the entire uterus was tissue into which the 



592 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

fingers could be pressed. This apparently indicated that the tumor 
had grown from the broad ligament and was closely associated with 
the uterus. The diagnosis was a probable intra-ligamentary ovarian 
cyst. Upon opening the abdomen the mass which we had sup- 
posed to be an ovarian cyst proved to be an oedematous fibroid. 
The mass to the right, which was firm, was a second fibroid in a 
more mature condition, and the soft line between them was the 
junction of the fibroid with the body of the uterus. 

^Dermoids are distinguished by their slow growth, greater mobil- 
ity, sensation of resistance, and absence of fluctuation. 

Adhesions. — Adhesions may be expected where a tumor has 
attained to very great size : under the pressure, the tumor suffers 
a loss of the endothelial layer of its covering peritoneum, roughen- 
ing of its surface follow^s, with a tendency to a slight peritonitis and 
the formation of adhesions. These are more likely to take place over 
the anterior surface of the tumor, and next in frequency between it 
and the omentum. The history of repeated attacks of peritonitis dur- 
ing the progress of the growth will almost certainly indicate exten- 
sive adhesions. They will occur also in inflammatory conditions 
of the cyst itself, whether resulting from torsion of its pedicle or 
from suppuration or gangrene. The mobility of the tumor or the 
ease with which the abdominal walls can be moved over it leads us 
to hope that adhesions are slight, though we cannot determine abso- 
lutely that it is free from them. 

Pedicle. — The enlargement of the ovary leads to its prolapse 
when by dragging upon its connection with the broad ligament it 
becomes more or less pedunculated. This elongation of its neck 
becomes increased when the tumor is large enough to rest in part 
upon the brim of the pelvis. The neck or attachment is known 
as the pedicle. It is composed in most cases of a part of the broad 
and ovarian ligaments, and generally contains the Fallopian tube. 
The thickness and length of the pedicle can only be determined 
with certainty at the time of removal. Where the tumor is freely 
movable it is reasonable to suppose that we have to deal with a 
long pedicle. Then by raising the tumor up and with the finger 
in the vagina, or, better, in the rectum, we may be able to feel the 
connection between the tumor and the uterine appendage. 

Exploo^atory Puncture. — In obscure and complicated cases the 
diagnosis may be rendered so difficult that in times past it has been 
deemed desirable to determine the character of the tumor and its 



DISEASES OF THE OVARIES AND TUBES, 593 

contents before deciding as to what operative procedure to adopt. 
To accomplish this, the removal and examination — chemical and 
microscopical — of a portion of the cyst-contents has been recom- 
mended. 

It should be remembered that the operation of aspiration of 
a cyst is not unattended with danger, as the intestines and 
bladder have been frequently panctured. There may be an escape 
of fluid into the peritoneal cavity or the entrance of air into the 
tumor, and the latter may be followed by gangrene or suppura- 
tion. A large vessel in the tumor-wall may be injured by the 
introduction of the aspirator, and an extensive hemorrhage result. 
In view of these dangers tapping is rarely justifiable. 

A proliferating cyst usually furnishes fluid of a thick, colloid 
character, with a specific; gravity of 1015-1030, which contains 
paralbumen and cylindrical epithelial cells. In the papillary 
cysts there is an absence of paralbumen, while the microscope 
discloses white blood-corpuscles. The fluid from the Graafian 
follicles is not distinguishable from that obtained from parovarian 
cysts. Ascitic fluid is thin, light yellow or greenish-colored, deposits 
albumen on boiling, does not contain cylindrical epithelium, and 
has a specific gravity of 1008-1015. In the cysto-fibromata the fluid 
has a lemon-yellow color, with a specific gravity of 1020, coagulates 
rapidly without heat, and does not contain cylindrical epithelium. 
The fluid from echinococciis cysts is distinguished by the booklets, 
and has a specific gravity of 1008-1010, without albumen. In 
hydronephrosis the fluid is thin, with a specific gravity of 1005- 
1018, varies in color, and contains urea, leucine, tyrosine, and 
kreatinine. Puncture in an ovarian cyst is always dangerous, and 
when performed for diagnosis in doubtful cases, as in echinococcus 
cysts, renal tumors, abscesses, or dermoids, it may be attended with 
the most serious consequences. The exploratory incision is a far less 
dangerous procedure. In cases in which it is impossible to arrive 
at a correct diagnosis, as in ascites from tubercular peritonitis or 
malignant disease of the ovary, tube, or omentum, or from papillary 
cysts, the buttonhole incision, through which one finger can be 
introduced, is far the preferable procedure, and, while admitting 
opportunity for the determination of the condition by touch, affords 
a subsequent opportunity for drainage. 

Treatment. — As the fluid is contained within a closed sac which 
has its own secreting surface, the administration of remedies or the 

38 



594 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

use of counter-irritants for the purpose of decreasing the accumu- 
lation by increased secretion and elimination is without reason. 
Electrolysis has been advocated, but when we consider the charac- 
ter of such growths and the danger of infection from many of them, 
it is too dangerous a plan to be considered. Surgical treatment con- 
sists of extirpation. Puncture is at best only a palliative measure, 
as the removal of the fluid is quickly followed by its re-accumula- 
tion, and is attended with great loss of albumen. The first puncture 
would necessarily be followed by others at shorter intervals, until 
the patient becomes exhausted by the severe drain. As has already 
been mentioned, it is attended with danger from the direct loss of 
blood, as the opening of a vessel, presence of papillary cysts, and 
rupture of a thin- walled cyst and the spreading of its papillary 
contents to the peritoneal cavity, as well as from septic infection. 
The operation may be done in pregnancy in the later stages in 
preference to ovariotomy as a temporary expedient, where the cyst 
is situated in the pelvis and would interfere with the delivery of 
the patient. Under these conditions the puncture should be made 
through the vagina. 

This is an exceedingly dangerous procedure, however, as the 
vaginal canal is difficult to render thoroughly aseptic. Puncturing 
the cyst through the rectum is under all circumstances absolutely 
unjustifiable. 

Ovariotomy. — The only treatment that is applicable to all cases 
and is worthy of consideration is the extirpation of the tumor, or ova- 
riotomy. Success in the performance of this operation will depend 
very much upon the care with which the diagnosis has been made, 
the knowledge of the operator concerning the condition of the 
patient, the dexterity with which the operation is performed, or the 
readiness in meeting complications, and the judicious treatment of 
patients subsequent to its performance. Preparation for the opera- 
tion will be considered, first, in the preparation of the patient ; sec- 
ond, of the room ; third, of the instruments and dressings ; fourth, 
of the operator and his assistants. 

The patient should have been carefully examined, and should 
be free from any febrile condition, or, if such is present, its cause 
should be ascertained. Operation should be avoided in the pres- 
ence of bronchial catarrh or inflammatory diseases of the lungs or 
other organs, unless absolutely necessary. The individual charac- 
ter of the pulse should be determined, the urine carefully exam- 



DISEASES OF THE OVABIES AND TUBES. 595 

ined, and laxatives administered for two nights preceding the day 
set for the operation, a few hours before which the rectum is 
emptied by enema. The patient should have been thoroughly 
bathed with hot water and soap each night for two or three nights, 
especial attention being given to the cleansing of the abdomen, pit 
of the umbilicus, and the external genitalia. The genitalia should 
be thoroughly shaved, and again washed with soap and water, fol- 
lowed by a bath of bichloride-of-mercury solution, and a vaginal 
injection of bichloride-of-mercury solution 1 : 2000, given the morn- 
ing before the operation. The abdominal walls should be covered 
with a pad wet with a bichloride-of-mercury solution, held in 
place by a binder, for at least two hours before the time for ojdc- 
ration. After the patient is placed upon the table, the abdomen 
should be thoroughly scrubbed by a towel wet with alcohol until 
the surface is reddened. She should be kept in bed for forty-eight 
hours prior to the operation, and be given food which produces 
little flatulence ; no solid food should be taken on the night preced- 
ing or on the morning of the operation. Owing to the large per- 
centage of casein and its tendency to produce flatulence, milk should 
not be considered a proper diet either before or immediately follow- 
ing the operation. Before the patient goes to the operating table 
it is preferable to have the urine voided. If there is any doubt 
about this being complete, the catheter should be used. 

Preparation of the Room. — The room if in a private residence 
and obtainable should be large, light, and well ventilated. The tem- 
perature should be about 75° F. It should be freed from all super- 
fluous furniture, as carpets and hangings. The floor and woodwork 
should have been thoroughly scrubbed with soap and hot water, 
and the walls wiped down with a damp cloth. The operating 
table should be of convenient height, and may consist, if other 
means are not at hand, of an ordinary kitchen table or of two 
kitchen tables placed at right angles to one another. It should 
be placed with the foot of the patient toward the window, so that 
the light may fall into the abdomen, and should be covered with a 
couple of blankets, over these a rubber cloth, and over this a sheet. 
There should be at hand three smaller tables — one for sponges, a 
second for instruments, and a third for the dressings. 

Instruments. — The operator should aim to have just as few in- 
struments prepared as is necessary to perform the operation, but, as 
it cannot always be determined beforehand in any individual case 



596 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

whether the operation will be a simple or a complicated one, it is 
well to have a second tray at hand with instruments that might 
possibly be needed. In the tray of necessary instruments should 
be placed a scalpel ; curved scissors ; dissecting forceps ; six small 
hemostats ; two large or pedicle forceps ; an ovarian trocar ; suture- 
carrier ; needle-holder ; half a dozen needles, straight and curved. 
In the second tray may be placed retractors, hemostats, pedicle 
forceps, and conveniently at hand, for use if necessary, there 
should be a Paquelin cautery. 

Sponges. — A definite number of sponges must be selected, about 
half a dozen in all — four small and two elephant ear. These should 
have been most carefully prepared as described in the consideration 
of Technique. The ligature and suture material consists either of 
catgut, silk, or silkworm-gut. Instead of sponges, gauze pads may 
be used: these are about eight to twelve inches square, made by fold- 
ing gauze until it forms eight layers, turning the raw edges in, and 
hemming so that there is no opportunity for threads to be left in 
the abdominal cavity. These pads should then be boiled in water 
to remove the sizing, carefully washed and placed in a 5 per cent, 
solution of carbolic acid. They are not as satisfactory for thor- 
oughly drying the abdominal cavity as are sponges. In addi- 
tion there should be at hand for every operation, ether or chloro- 
form as is preferred for anesthesia ; strychnine in solution, or in 
tablets of one-twentieth or one-thirtieth of a grain ; nitrate of amyl 
and nitro-glycerin, atropine one-eightieth of a grain, and Monsel's 
solution. The instruments should be placed in trays on a table to 
the right of the operator, where he can reach them without the aid 
of an assistant. 

The patient, after the administration of the anesthetic, is placed 
upon the table, having the lower extremities covered with a clean 
blanket, over which a sterilized sheet is spread. The clothing is 
drawn well up under the arms, front and back, and the upper part 
of the body covered with a sterilized blanket ; over this are placed 
sterilized towels, one above, one below and one on either side, fast- 
ened by safety-pins. These pins should be placed under the towel 
or the towel may be laid on the abdomen, pinned about an inch and 
a half or two inches from its border, and then turned back toward 
the side on which it is placed ; the opposite side may be prepared 
in a similar manner. In this way the safety-pins are covered and 
out of the way. The whole is covered over, by a large piece of 



DISEASES OF THE OVABIES AND TUBES. 597 

Sterilized gauze with a slit cut in it corresponding with the site of 
the abdominal incision. 

After cleaning the hands, the operators and assistants must 
exercise the greatest watchfulness and care not subsequently to 
touch any non-sterilized object. If by chance the hands should 
be touched or come in contact with anything that has not been 
cleansed, the operator or assistant should discontinue the operation 
until he can re-sterilize his hands. A basin of hot water should 
be placed on the table alongside of him, with directions to the 
nurse that it shall be changed from time to time. In this the 
hands should be washed whenever soiled with blood or pus 
during the progress of the operation. The assistants should 
consist of an anesthetizer, who must devote himself most care- 
fully to the patient, watching the pulse and respiration, and under 
no circumstances failing to note changes in her condition. A prin- 
cipal assistant should stand opposite the operator to the right of 
the patient. Behind him, within easy reach, is a table with two 
basins for the sponges, in one of which they are kept in clean water 
until needed. As they become soiled they are thrown into the sec- 
ond basin, where after being washed out by the nurse they are placed 
in the former one. It is well to divide the sponges into two lots, 
having one lot in a reserve basin to be used in case the first becomes 
soiled. The nurse in charge of the sponges must, under no circum- 
stances, fail to keep a record of the number in use, and should be 
able at any time to state their location. If a sponge falls upon the 
floor or comes in contact with any septic object, it should not again 
be used, but its position should be remembered, so that in enumera- 
ting them at the close of the operation there will be no possibility 
of mistake. This is a very important direction, as numbers of cases 
are upon record in the experience of skillful operators where through 
negligence sponges or other articles have been left within the ab- 
dominal cavity, leading either to the death of the patient or to the 
necessity of reopening the wound in order to remove them. 

With a nurse in charge of the sponges, a fourth assistant is 
desirable, to be ready for emergencies : he may look after the thread- 
ing of needles, preparation of sutures, and the Paquelin cautery. 
In the great majority of cases the patient will be placed under the 
influence of ether for the operation. In those cases, however, in 
which examination has disclosed either a defective condition of the 
kidneys or the presence of albumen, chloroform is the safer anes- 



598 AJSr AMERICAN TEXT-BOOK OF GYNECOLOGY, 

thetic. In the administration of chloroform it is important that it 
should be given carefully, securing with it a sufficient quantity of 
air. It is well to use a napkin, handkerchief, or several layers of 
gauze, dropping the chloroform upon this, allowing a sufficient 
amount of air to be inspired with it to render its use safe. In the 
administration of ether, the pure vapor, unadulterated with air 
should be given. In some patients the ether acts slowly and leads 
to considerable struggling. This may be avoided by the previous 
administration of bromide of ethyl, which acts very quickly and 
with scarcely any excitement. The anesthesia with ether may be 
commenced while the patient is under its influence, or a hypoder- 
mic injection of morphia, a sixth or a quarter of a grain may be 
administered one-half hour before the anesthesia. Having a patient 
anesthetized and placed upon the table, surrounded with sterilized 
blankets and towels, and the abdomen cleansed, we are ready for 
the operation. 

Operation. — In considering the conduct of the operation we pre- 
fer to divide it into different steps or stages and describe the method 
of procedure in each. By so doing we feel that we can impress 
upon the would-be operator a graphic outline of the various acci- 
dents which may occur and the subterfuges to which he may resort 
as he proceeds. We do not feel that he can deviate from a safe 
course in completing the entire journey if an accurate chart of each 
portion is presented. The different steps are : 

1. Incision of the abdominal wall ; 

2. Puncture, emptying, and removal of the cyst ; 

3. Management of adhesions ; 

4. Management of the pedicle ; 

5. Toilet of the peritoneum ; 

6. Drainage ; 

7. Closing of the wound ; 

8. Dressing. 

A description of the abdominal incision will be found else- 
where. 

After incision of the peritoneum, the pearly, glistening surface 
of the cyst is exposed. The peritoneum should be held up, and 
the first incision in it carefully made to avoid injuring the cyst or 
coils of intestines. If there are adhesions the finger should be in- 
troduced through the small opening of the peritoneum and the in- 
cision extended by the use of probe-pointed scissors. The intro- 



DISEASES OF THE OVARIES AND TUBES. 599 

duction of the finger guards against injury of the intestine or cyst. 
At the lower part of the wound it discovers the bladder and pre- 
vents its being wounded. The peritoneum may be overlooked and 
cut through, and the omentum mistaken for preperitoneal fat ; in 
the latter the vessels are transverse, in the former vertical. Where 
the peritoneum is firmly fastened to the parietes of the cyst it may 
be difiicult to determine when it is reached. The cyst-wall should 
be incised, the cysts emptied, and an attempt made to withdraw the 
posterior wall, or the incision in the abdomen may be carried up to 
the umbilicus, where the layers of the abdominal wall become fused 
together, when the cyst- wall will be more easily recognized. After 
the peritoneum is incised, as a preliminary step to further pro- 
cedure it should be fastened to the integument by one suture 
about the middle of either side of the wound. This prevents it 
being pushed off from the abdominal walls during the further 
manipulation. 

Emptying the Cyst. — The cyst projects into the wound, present- 
ing a pearly, glistening appearance. The trocar, with a rubber tube 
attached, long enough to dip into a receptacle placed beneath the table, 
is then plunged into the cyst, choosing a point for its introduction 
which will empty the large or main cyst and is free from large ves- 
sels. This puncture should not be made at the lower angle of 
the wound, for the reason that as the cyst empties it retracts and 
leaves the opening situated below the wound, increasing the dif- 
ficulty of preventing the fluid from flowing into the abdomen. As 
the trocar is plunged into the cyst the abdominal walls are held close 
about it, and sponges should be packed around the orifice to pre- 
vent any fluid running back into the peritoneal cavity. As the 
sac becomes relaxed it is grasped with hemostats, and later with 
cyst forceps, and drawn out, keeping the opening in the cyst out- 
side the abdominal wound. The assistant will place his hands upon 
either side of the abdomen or above it, making pressure, which forces 
out the fluid and keeps the wound stretched over the projecting sur- 
face of the cyst. If there are a number of cysts, the trocar may be 
passed from one into the other. In this procedure, however, it is 
important that the hand should be passed into the abdomen around 
the cyst to prevent the trocar from perforating its main wall, injur- 
ing the viscera or abdominal tissues, or permitting the escape of fluid. 
Where a trocar of suitable character is not at hand, the parts may 
be drawn tense around the cyst, puncture made into it with a knife, 



600 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the edges grasped with forceps, drawn out, and the orifice thus kept 
outside the abdominal cavity. Other cysts may be opened through 
the first cyst, and their cavities broken down by the hand passed 
through the opening. This, in some cases, may be necessary, owing 
to the consistency of the fluid being such that it will not readily flow 
through the trocar. In small cysts it is preferable to introduce the 
hand and break up the cysts rather than to attempt to pass the trocar 
in different directions to empty them. As the cyst is emptied it is 
also drawn out, so that in a single cyst, or in a multilocular cyst 
which is not adherent, the emptying is followed or partially preceded 
by the withdrawal of the sac. Where the cyst has thick, viscid 
contents, it may be necessary to draw it well up into the wound 
before opening it, or possibly, after turning the patient upon her 
side, to press back the abdominal wall from the under side, open 
the cyst, and, dragging the opening still farther out, break up the 
contents. In this way a cyst of considerable size may be brought 
through a small opening. AVhere there is considerable solid 
material in the cyst, however, requiring some difficulty to bring 
it through the opening, the latter should be enlarged, rather than 
to subject the patient to much manipulation in order to avoid a 
large opening. In dermoid cysts or those in which suppuration 
has occurred it is better that a larger opening should be made and 
the cysts removed entire. When the contents of dermoid cysts 
flow into the abdominal cavity it is exceedingly difficult to remove 
them and to neutralize their irritating effect. The material is oily 
in character, and does not wash out readily by irrigation ; for such 
reasons it is preferable that the cyst should be removed intact. 

Adhesions. — The ease with which adhesions may be managed 
depends much upon their character. In recent cases, where the 
cyst has undergone inflammatory action, resulting in adhesive peri- 
tonitis, the adhesions may be readily overcome by the use of the 
sponge. It is sometimes recommended to introduce the hand into 
the abdominal cavity before the cyst is punctured and separate or 
break up the adhesions. This can readily be done over the anterior 
parietes, where the adhesions are soft, but dense, firm adhesions should 
preferably be separated at the wound under the guidance of the eye. 
Consequently, after the cyst has been wholly or partially emptied, 
it is drawn out, and where adhesions of a soft and friable character 
exist, these are separated by pressing the viscera off from the sac by 
a sponge. Adhesions will depend in gravity upon their situation 



DISEASES OF THE OVARIES AND TUBES. 601 

and duration. The older the adhesions, the more thoroughly or- 
ganized they become and the more difficult they are to separate, 
requiring, in some cases, the use of the scissors or knife. Parietal 
adhesions, where they cannot be sponged off, may be separated by 
the finger, tearing the surfaces from the cyst-wall, or, where this 
cannot be accomplished, by using the scissors. Not infrequently 
considerable bleeding will take place. Omental adhesions are fre- 
quently long and quite vascular, so that they are preferably tied 
with double ligature and cut between, using for this purpose pre- 
pared catgut. Adhesions that are difficult to manage are those 
between the intestine and other abdominal viscera and the cyst- 
wall. Such adhesions may take place between the coils of the 
intestine, the stomach, the spleen, the liver, and the gall-bladder. 
Adhesions to some of these organs are exceedingly firm and only 
separated with considerable difficulty. Where the adhesions are 
long they may be separated by means of the scissors or by grasp- 
ing the adhesions with a clamp and burning through the tissues 
with the cautery. When the adhesions to the intestine, for instance, 
are sessile, the removal of the neoplasm may be attended with con- 
siderable difficulty. In some cases adhesions are very close, and their 
removal would involve the structure of the bowel, impairing its vital- 
ity. It is then preferable that the cyst- wall should be cut through, 
leaving a portion of it attached to the intestine, taking the precaution 
to remove the epithelial lining membrane, thus taking away the 
entire secreting surface of the cyst. Pelvic adhesions of long dura- 
tion are the most difficult to manage and the most dangerous in 
character. A tumor which has been situated low down in the 
pelvis, filling it, may be adherent to the large arterial or venous 
vessels. The author never had a more trying or sadder experience 
than in a woman of sixty-three years of age, the mother of a phy- 
sician, who had a thin-walled cyst, which was completely emptied, 
and was only adherent in the pelvis. On making gentle traction 
upon the cyst, endeavoring to push off the pelvic tissues, there was 
at once a sudden filling up of the entire pelvis with venous blood, 
showing that a large vein had been injured. The hemorrhage was 
controlled by packing the pelvis with sponges, removing the blood, 
but the patient was already profoundly shocked. After the removal 
of the sponges the pelvis was packed with iodoform gauze, which 
was brought out at the lower angle of the wound. She lived but a 
few hours after the completion of the operation. 



602 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

In some cases the adhesions will be found extending down into 
Douglas's cul-de-sac, requiring an universal enucleation. In par- 
ovarian or broad-ligament cysts we may find the broad ligament 
spread out and covering the cyst-wall. In such cases it is import- 
ant to examine carefully the tissues as we progress, for the tumor 
may be found to have begun its development deep in the broad 
ligament, and may have pushed above it the ureter, as was found 
by the author in one case of broad-ligament cyst : after opening 
the cyst and commencing to enucleate, the ureter w^as found to pass 
directly over it. Attempted enucleation would have been attended 
with so much injury to the ureter as to have imperiled its vitality. 
For this reason the tumor was completely em23tied, washed out, and, 
with a view of securing drainage, stitched to the abdominal wound 
and its cavity packed with iodoform gauze, in order to set up inflam- 
matory changes within it to destroy its secreting surface and lead to 
adhesion of its walls. In this, however, we regret to say, the opera- 
tion was not a success, as the patient appeared a few months later 
having a cyst fully as large as the one for which we had operated. 

Papillary cysts may develop beneath the broad ligament, and 
infiltrate the tissues to such a degree as would render their removal 
almost impossible, or, if removal were performed, would leave a 
large, ragged, raw surface which necessarily increases the danger to 
the patient. In bleeding following the separation of extensive adhe- 
sions, not arrested by irrigation with hot water, it may be necessary 
to resort to either the use of Monsel's solution, wetting a sponge 
with 1:4 of the solution and wiping it over the oozing surface, or 
the use of the Paquelin cautery. Where the adhesions have been 
to the anterior parietes in very large cysts, large raw surfaces are 
exposed ; that is, the peritoneum is torn through. The bleeding 
may be controlled and unfortunate intestinal adhesions avoided 
by introducing sutures through the abdominal wall in such a way as 
to approximate the large raw surfaces and thus shut them out of 
the abdominal cavity and promote their union. 

Pedicle, — After emptying the cyst and drawing it out, the 
empty sac is found to be attached to the abdominal cavity by 
a more or less narrow band of tissue which is known as the 
pedicle. It consists in the majority of cases of the ovarian 
ligament, a part of the broad ligament, with not infrequently the 
tube extending up over the cyst. There has been much discussion 
in the past upon the proper treatment of the pedicle — whether it 



DISEASES OF THE OVARIES AND TUBES. 603 

should be treated intra- or extra-peritoneally ; in other words, 
whether it should be ligated or the vessels otherwise secured and 
dropped back, or should be brought back and fastened in the lower 
angle of the w^ound. In the latter method of treatment it has been 
the custom to use the clamp. This clamp method for many years 
was practised by Atlee, Wells, and contemporary operators. Its 
advantage was the security against hemorrhage and the fact that 
the pedicle was constantly under observation. It had the disad- 
vantage of requiring a longer time for convalescence ; the pedicle 
sloughed off, increasing the danger of septic infection, leaving a sur- 
face to heal by granulation, and in some cases has resulted in subse- 
quent menstruation from the stump. The intra-peritoneal method 
is that which is now universally practised. The pedicle may be 
ligated or cauterized, as has been recommended by Keith. Cauteri- 
zation is performed by grasping the tissue of the pedicle in a clamp, 
one side of which is covered w^ith ivory plates to prevent the heat 
being conveyed to the tissues beneath, and searing the included 
tissues by cautery iron heated to redness. The method is danger- 
ous, and not to be used under any circumstances where it is pos- 
sible to place a ligature. Operators universally prefer the use of 
the ligature. The pedicle, when of ordinary size, is transfixed and 
tied in two portions. The ligament should be transfixed with a 
double ligature, cut, and each half tied separately and then both 
the ends together, or one ligature may be carried around, tying it 
over both parts. Where we have a large tumor made up of solid 
material, which it would require considerable effort to hold and pre- 
vent traction upon the pedicle, the latter may be seized with pedicle 
forceps immediately beneath the cyst, to secure the patient from loss 
of blood, and the tumor cut away, after which the pedicle may be 
tied in the manner we have already described. In removing the 
tumor it is important to leave a sufiiciently long stump above the 
ligature to prevent the possibility of a portion of the tissue being 
retracted, permitting hemorrhage to take place from either the 
ovarian or uterine arteries. For ligation of the pedicle either silk 
or catgut may be used. The catgut is preferred by some operators 
for the reason that it, being an animal ligature, is absorbable and 
will not remain to give rise to irritation subsequently. Its disad- 
vantages are that the ligature may slip, affording an opportunity 
for hemorrhage to occur after the wound has been closed, and the 
catgut being septic may cause infection of the peritoneal cavity. 



604 AN AMEBIC AN TEXT-BOOK OF GYNECOLOGY. 

Where the pedicle is a broad one and a short stump is left above 
the ligature, it is preferable to introduce a second one, including 
that portion of the pedicle through which the ovarian artery passes, 
so that in case the ligature should slip this large vessel would still 
be controlled. An illustration of this procedure is given under the 
heading of Pelvic Inflammations. A broad, fleshy pedicle should 
preferably be tied in a number of sections, the ligatures being 
introduced and tied as seen in the accompanying figures. After 

Fig. 348. Fig. 349. 



V^^^ 





^^S^i^ 



Triple Interlocking Ligature ; the threads in- Triple Interlocking Ligature ; the threads 

serted. interlocked ready for tying. 

the removal of a cyst and ligation of the pedicle the operator should 
examine the condition of the other ovary, and should it show signs 
of cyst-growth it is also to be removed. In some tumors, particu- 

FiG. 350. 




Triple Interlocking Ligature tied. 

larly the broad-ligament cysts and parovarian cysts, no pedicle will 
be found. These tumors dip down into the broad ligament along- 
side of the uterus. In such cases it will be necessary to peel out 
the cyst, and ligate any vessels that may be found to bleed, or, 
if the bleeding be from a large surface rather than from distended 
vessels, it may be controlled by gauze packing. 

Peritoneal Toilet. — Where a simple uncomplicated cyst has been 
removed the necessary toilet of the peritoneum is slight. It con- 
sists in sponging out the cavity or in introducing a sponge to ascer- 
tain that there is no sign of bleeding, when the cavity may be closed. 
Where adhesions have been extensive, it is important to examine 
carefully to see whether or not bleeding still continues, and if so, to 
take measures to control the hemorrhage. If the omentum has been 



DISEASES OF THE OVARIES AND TUBES. 605 

torn off from the cyst and shows signs of bleeding, it should be 
turned up over a towel wrung out of hot water, carefully exam- 
ined, and bleeding points ligated with catgut. All bands of adhe- 
sion or openings in the omentum should be tied and cut away, as 
they only afford an opportunity for a knuckle of intestine to slip 
through and thus endanger the patient from obstruction of the bowel 
in the subsequent convalescence. Where there has been much bleed- 
ing and the abdominal cavity has been soiled with discharges from 
multilocular or papillary cysts, it should be thoroughly irrigated. 
The preferable fluid for this purpose is a 0.6 per cent, solution of 
common salt, of which, if necessary, several gallons may be used. 
It may be poured into the abdominal cavity from a pitcher, or 
through a funnel with a rubber tube attached, having a metallic 
end long enough to pass into Douglas's pouch ; the water should be 
permitted to flow in until it runs out clear. After irrigation the 
superfluous fluid may be sponged out, or if the drainage-tube is 
used it may be left. A flat sponge is placed beneath the wound, 
over the intestines, in such a way as to cover them and keep them 
back while the sutures are introduced. The sutures, which are pre- 
ferably of silkworm-gut, may be introduced in a single row, carry- 
ing each one through all the tissues including the peritoneum, exer- 
cising care in their introduction that the aponeurosis shall be drawn 
well forward over the recti muscles when they are tied. Preferably 
a separate row should be passed through the aponeurosis. 

Before closing the wound we must consider the subject of drain- 
age. When shall drainage be used ? If used, what shall be its 
character ? What shall be the method by which it will be accom- 
plished ? The question of drainage is one which has been much 
discussed of late years, some operators advocating that every case 
should be drained, others none. Its true place lies between these 
extremes. Every case in which extensive adhesions have been sep- 
arated should be subjected to drainage. Those cases also in which 
there has been soiling of the peritoneal cavity by the contents of 
dermoid cysts or suppurating cysts should be given thorough and 
careful irrigation and subsequent drainage. 

As to the form of drainage : a glass tube, as illustrated in the con- 
sideration of Technique, is generally preferred. The perforations at 
the bottom of the tube should be perfectly smooth, depressed rather 
than elevated, and small, to prevent the entrance of the intestinal 
walls by intra-abdominal pressure, rendering the removal of the 



606 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

tube difficult and painful, and increasing the danger of lighting 
up inflammation. The objection to the glass tube is that it re- 
quires frequent emptying, and even with the most careful practice 
there is danger of the entrance of pathogenic germs into the peri- 
toneal cavity through it. Another method of drainage is by the 
gauze drain, which is also described under Technique. Its advant- 
ages are that there is no possibility of septic infection of the abdom- 
inal cavity. When the drain is removed, which may be at the end 
of twenty-four to seventy-two hours, it may be replaced by a steril- 
ized rubber tube. The gauze drain is much less likely than the 
glass one to be followed by a fistulous tract ; the tract occupied by 
it usually heals almost as soon as the remaining portion of the 
wound. 

After the wound is closed, the abdomen should be carefully 
washed with a 1 : 2000 bichloride-of-mercury solution, and a sponge 
wet in the solution squeezed over the wound. The wound is then 
to be dried with a sterilized towel, and protected by pressure made 
over it while the sides and back are dried, and the patient placed 
upon a dry sheet or blanket. The dressing may then be applied. 

Dressing. — The dressing described in the consideration of 
Technique may be used, or the following substituted. It is simple 
in character, consisting of first dusting the wound with iodoform 
which has been carefully sterilized. This is best done by placing 
the powder in a test-tube, which is immersed in boiling water for 
half an hour, and then put in a carefully sterilized box with a perfor- 
ated lid. The plan of using the iodoform from pill-boxes covered 
with gauze, which have been standing in the wards of a hospital, 
is reprehensible, as germs may accumulate in the iodoform and 
thus be brought in contact with the wound. The iodoform decom- 
poses, neutralizing the ptomaines or germ-products, and does not act 
as a germicide. After dusting the wound it is covered with several 
pieces of sublimated gauze lightly applied; over this is placed 
a layer of salicylated cotton, followed by a layer of borated gauze 
or a sterilized towel, which is held in place by strips of adhesive 
plaster to which tapes have been attached. These strips are fastened 
to either side of the abdomen, and not too far back, as in that case 
the tapes make unpleasant pressure upon the skin, but just so far 
that their anterior edges will come in close proximity to the 
dressing. The tapes are tied over the dressing and the whole is 
held in place by a flannel or crinoline bandage. This dressing 



DISEASES OF THE OVARIES AND TUBES. 607 

is expected to remain for a week or ten days, unless there are 
indications for its early removal. Where drainage by a glass tube 
is used a piece of rubber dam about six or eight inches square, 
having a small opening made in its centre, is stretched over the 
flange of the tube. The tube is covered with a piece of sterilized 
gauze or absorbent cotton which has been wrung out of a weak 
solution of bichloride-of-mercury, and the rubber dam pinned over 
it, protecting the dressings from being soiled. The gauze drain 
if used should be surrounded by a good thick layer of dry gauze, 
which should be changed as frequently as it becomes saturated. 
The drier the external dressing is kept, the more thoroughly and 
effectively will it drain. 

In ordinary uncomplicated cases the duration of the operation 
may not be over twenty to thirty minutes. The shorter the time 
required by the operation consistent with careful attention, the bet- 
ter for the patient. 

The method of managing patients after ovariotomy will be found 
described in the consideration of After-treatment. 

Accidents during the Operation. — Stripping off the Parietal 
Peritoneum. — This accident is not likely to occur where care is 
observed. The operator may overlook the peritoneum, and sup- 
posing that it has been opened, push it off from the abdominal 
walls. More frequently, however, it is likely to be opened without 
being recognized, and the omentum beneath regarded as the pre- 
peritoneal fat. As has already been observed, this may be avoided 
by noticing that the vessels in the transversalis fascia run trans- 
versely, while those in the omentum are vertical. When the 
omentum is fastened down over the tumor, it is better to find its 
point of attachment, and tear it up, rather than to open through 
the omentum itself, on account of the probability of bleeding. The 
peritoneum may be stripped off during manipulation, as in the 
introduction of sponges to keep the surfaces dry during the intro- 
duction of the sutures. If the opening is small, in introducing a 
sponge the peritoneum may be pushed in front of it, and a con- 
siderable surface be stripped off. Where this has occurred it is 
better to cut away a portion rather than to risk gangrene. 

Rupture of the Cyst. — In delivering the cyst, particularly where 
the walls are fragile, it may be torn through, permitting the contents 
to float into the abdominal cavity. This is not an accident of 
serious importance unless the contents of the cyst are putrid in cha- 



608 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

racter, as in suppurating cysts, or, again, in the dermoid varieties, 
where the oleaginous material is exceedingly difficult to wash out 
of the cavity. Tearing of the wall of the cyst during its removal 
necessitates a thorough irrigation of the abdominal cavity to neu- 
tralize or remove its contents. 

Fatal Hemorrhage. — Fatal hemorrhage during operation was 
formerly an event of greater frequency than it has been of late. 
The site of the hemorrhage will have much to do with its character : 
in large cysts with extensive adhesions we may have hemorrhage 
taking place from the cyst itself or from vessels that may be torn 
within its walls, giving rise to a serious condition. In such cases the 
course of treatment should be to rapidly separate, lift out the cyst, 
secure its pedicle, and so cut off the supply of blood. In separa- 
ting adhesions the larger and more vascular should be separated 
between two ligatures or between a ligature and a pair of hemostats. 
If the hemorrhage is of a serious character, the assistant may place 
his hand within the abdomen and compress the abdominal aorta, 
maintaining the pressure until after the operation is completed. 
Such a procedure prevents further supply of blood being sent to 
the tumor, and so arrests the hemorrhage. We may find hemor- 
rhage take place from a very extensive surface, particularly after 
the removal of malignant disease, or extensive papillary growths 
behind the uterus, involving its entire posterior surface and the 
pelvic viscera. In a recent case the diseased tissues were hurriedly 
removed, and the cavity and bleeding surfaces above were com- 
pressed by a number of antiseptic towels packed into the abdom- 
inal cavity. This thoroughly controlled the bleeding, but the 
patient was so enfeebled prior to the operation, and still further 
exhausted by the bleeding, that she died shortly afterward. Fatal 
syncope and death may take place in very large tumors from the 
decreased abdominal pressure. Vessels relieved from pressure be- 
come distended by the blood, forming reservoirs, until so much 
is withdrawn from the circulation that the resulting cerebral 
anemia is sufficient to cause the death of the patient. In such 
cases the patient may be said to have bled into her own vessels. 
Such an occurrence is only likely to take place in very large 
tumors, and may be obviated by emptying the cyst slowly. When 
syncope occurs the head should be lowered, the limbs wrapped in 
warm blankets or bandaged, and an assistant may compress the 



DISEASES OF THE OV ABIES AND TUBES. 609 

aorta directly with the hand in the abdominal cavity, while the 
treatment of the pedicle and the toilet proceeds. 

Visceral Injuries. — Injuries to the viscera, particularly the intes- 
tines, are likely to occur during complicated operations. It is im- 
portant before opening the peritoneum to lift it up by forceps, and 
make a small incision into which the finger can be introduced. 
The importance of doing this under the eye can be appreciated 
when we remember that a coil of intestine may be situated between 
the tumor or cyst and the abdominal parietes, adherent to the lat- 
ter, when an incision blindly made might result in cutting into or 
through the intestine. Where adhesions are dense the intestine 
may be torn into or even across during the progress of the opera- 
tion. Where such lesions occur the parts should be carefully 
repaired at once, and measures exercised to prevent soiling of the 
peritoneal cavity with the contents of the bowel. The intestine 
should be carefully sutured, and, when torn through to such a 
degree as to render the vitality of the parts uncertain, its resec- 
tion and an end-to-end or lateral anastomosis should be practised. 
Where the operator is provided with rubber rings, as devised by 
Baldy and Ashton, or bone plates, the lateral anastomosis will be 
most quickly done. The procedure consists in first closing up the 
ends of the gut by inverting them, suturing the peritoneal surfaces, 
and then making an incision near each end upon surfaces which 
can readily be brought in apposition, fixing these incised surfaces 
in contact with each other by the rings or plates, which are fastened 
together generally by four ligatures from each plate. The peri- 
toneal surfaces are then sutured with a row of sutures, preferably of 
catgut. The end-to-end anastomosis may be done by simple sutur- 
ing of the surfaces, beginning with sutures between the muscular 
surfaces, and then a second row around the peritoneum, so that con- 
siderable peritoneal surface is opposed. The most difficult cases 
to suture are those in which the rectum has been torn during the 
operation. Then, again, portions of the bowel may be so devitalized 
that they subsequently slough, giving rise to fecal fistula. In tumors 
situated low down in the pelvis, those that have developed in the 
broad ligament, and particularly in the papillary forms of ovarian 
growth, it is quite important to keep in mind the position and rela- 
tion of the ureter, as this organ may be pulled up or torn off* in the 
enucleation of such masses. It has been referred to in a case which 
came under the observation of the writer in which the ureter passed 

39 



610 ^iV^ AMERICAN TEXT-BOOK OF GYNECOLOGY, 

directly over the upper surface of a large cyst, and came very near 
being cut or torn in two during the effort at its enucleation. The 
bladder may be situated in such a position that it may be injured 
during the abdominal incision or during the progress of the opera- 
tion. Thus, where the bladder is drawn up by contact with the 
cyst and spread out over its anterior surface, it may be overlooked 
before its true character is suspected. The entire fundus of the 
bladder has been cut away in the removal of cysts. It has been 
the misfortune of the operator to open into the bladder before he 
realized its true character. The peculiar interlaced muscular struc- 
ture of its wall should cause it to be recognized immediately. 
Wherever the bladder is opened or injured it should be sutured. 
In the case in which the entire summit of the bladder was cut 
away the walls were sutured, opposing a good extent of the outer 
wall, and the patient recovered. In such injuries it is important 
also to prevent the bladder becoming unduly distended during the 
convalescence, especially for the first few days. It should be 
emptied frequently, in order that the accumulation may not lead 
to separation of the weak union and consequent leakage of urine. 

Incomplete Operations. — We are unable by our most accurate 
rules of examination always to arrive at a correct and definite dia- 
gnosis of either the disease or the structures involved. 

An incision of the abdomen may reveal that a tumor is so situ- 
ated or so extensively adherent to surrounding structures as to 
render its removal impossible. Incomplete operations were formerly 
much more frequent than at present. Indeed, there are few cases 
in which an operation for the removal of a tumor should be dis- 
continued after it has once been begun. In those cases, however, in 
which an exploratory incision discloses that the disease is malignant, 
and has already infiltrated tissues which cannot be safely removed, 
or secondary nodules are found in tissues remote from its origin, the 
acquisition of such knowledge should be considered a bar to further 
procedure. If upon opening the abdomen it is found that the entire 
peritonea,l cavity is studded with papillary growths resulting from 
infection of the peritoneum through the rupture of a papillary cyst, 
it would be unwise to subject such a patient to the danger incident 
*upon the removal of the original source of the disease. 

The cases in which complications too grave to permit of the com- 
pletion of the operation exist may be subjected to mere closure of the 
wound where the parts have not been much disturbed ; in others it 



I 



DISEASES OF THE OVABIES AND TUBES. 611 

may be necessary to drain : this may be done by a glass tube or pre- 
ferably by gauze drain, which is efficient and free from the dan- 
ger of injuring the structures of the pelvis. Where a cyst has 
been opened, or in any case in which it has been injured, but is 
found connected with other tissues by firm adhesions to such a 
degree as to render removal impracticable or unwise, the cyst may 
be opened, emptied of its contents, brought out and stitched fast to 
the abdominal wound. The superfluous portion should be cut away. 
The cavity may be packed with iodoform gauze, which promotes 
drainage, and by its presence in the sac may lead to an inflam- 
mation which will cause its obliteration. 

Sequels. — The subsequent progress of a patient who has been 
subjected to ovariotomy will depend much upon the manner in 
which the operation has been conducted. In spite of every pre- 
caution that may be taken, there will be some cases of delayed con- 
valescence, due possibly to some latent or pre-existing pathological 
tendency ; but when an operation is carelessly performed and its 
details are imperfectly carried out, the probability of serious trouble 
can be appreciated. The operator and his assistants should have so 
trained themselves that the slightest deviation from a proper course 
cannot go unnoticed. Of what avail is it to spend much time in 
securing cleanliness of person, room, and instruments, and then 
drag the ligature with which the pedicle is to be secured over 
blankets or dirty tables before its introduction ; to dust the wound 
with iodoform from a box that has been standing open and used in 
all sorts of cases about a ward ; to rub the nose, scratch the head, 
or touch other non-sterilized objects, and place the hand in the 
cavity without any precautionary cleansing ? Such indiscretions will 
often explain stitch-abscesses and other septic processes. Pus-col- 
lections and cellular inflammations will occur in the pelvis about 
and posterior to the uterus, due possibly to some infection of serous 
collections in Douglas's pouch. Elevation of temperature, rapid 
pulse, and pain continued after the fourth or fifth day should lead 
to a careful examination for its origin. A mass of exudation in the 
pelvis should be considered an indication for the administration of 
salines in free doses until purgation, and the use of rectal and vag- 
inal enemata of hot water at least twice daily. The exudation 
should be carefully watched, and the appearance of softening, felt 
either through vagina or rectum, should be considered as requiring 
prompt evacuation. The latter is accomplished by an opening 



612 ^iV^ AMERICAN TEXT-BOOK OF GYNECOLOGY, 

through the vault of the vagina behind the uterus. The vagina 
should have been previously carefully disinfected, and the pus-cav- 
ity should be irrigated with hydrogen peroxide, followed by sterilized 
water, and packed with iodoform gauze. 

When discussing the details of the operation we endeavored to 
render prominent the importance of having the nurse acquainted 
with the number of sponges and catch- forceps in use, and making 
sure all were removed before the abdomen was closed. That the 
importance of this precaution has not been exaggerated may be 
appreciated when we find it recorded that a retained sponge was the 
cause of death in one of Tait's cases ; that Spencer Wells has 
removed a pair of forceps the following day ; that Asdale re-ope- 
rated a year later to remove forceps, and was obliged to resect the 
intestines ; and many other such cases have been recorded. But 
recently a patient came under observation in whom a skillful opera- 
tion was rendered less beneficial by the presence of a gauze pad 
which was removed some months later. 

Intestinal Complications. — After operations for inflammatory 
troubles intestinal complications are not infrequent. It is difficult 
to make sure the intestines are free from twists when replaced, but 
danger is aggravated when we have bands of inflammatory adhe- 
sions, or openings in the omentum or mesentery, beneath or through 
which a knuckle of intestine may slip and become strangulated. 
Laceration of the coats of the intestine will afiect its peristaltic 
action, and may lead to paralysis of a section, with ensuing symp- 
toms of obstruction. A twist or volvulus may become fixed so that 
nothing can pass through it. If the walls are already weakened, a 
fecal fistula may ensue, as has occurred in our experience during the 
past year. A woman, much prostrated by puerperal sepsis, was sub- 
jected to abdominal section, the pus evacuated, forming as it did reser- 
voirs in front and behind the uterus, and the abdomen irrigated and 
drained. She did well for a few days, when a discharge of feces 
occurred, and upon her death some weeks later a volvulus was 
found. In a case operated upon at the Philadelphia Hospital by 
a colleague obstruction occurred five weeks after operation. The 
patient was seized with stercoraceous vomiting. A resection was 
performed and five feet of intestine torn up, finding at its base a 
distinct volvulus, which was untwisted. The patient recovered 
after a prolonged convalescence. The importance of early re-open- 
ing the abdomen in such cases cannot be over-estimated, as the 



DISEASES OF THE OVARIES AND TUBES, 613 

obstruction may be due to strangulation of a knuckle of intestine 
beneath inflammatory bands or to its enclosure between the sutures 
in the wound. 

Fecal Fistulce. — The proper method of treatment of fecal fistulse 
is still a debatable question. If the opening is small, it may be 
left to Nature with the assurance that with cleanliness it will close. 
Should it be large and all the feces pass through it, and particu- 
larly if it be situated high up, the better plan would be to reopen 
the abdomen and seek for the opening in the bowel, and close it or 
resect a portion of the intestine as may seem best. 

Adhesions. — It is quite probable that no case subjected to opera- 
tion is subsequently free from adhesions, though their frequency and 
extent will depend somewhat upon the presence of sepsis. The more 
aseptic the operation and the less the peritoneum is injured, the 
slighter and more fragile will be the adhesions. 

They are more likely to take place between the abdominal 
incision and the underlying viscera, and between the stump of the 
pedicle and adjoining coils of intestines. The former may be ren- 
dered less annoying by drawing down the omentum to protect the 
wound, and the stumps may be turned forward and stitched to the 
anterior fold of the broad ligament. Dusting a film of aristol over 
the intestines to prevent adhesions has been recommended, but the 
procedure is of little practical use. Where adhesions have formed 
pain may be caused by traction upon them during the peristaltic 
action of the intestines. Pain thus caused has been so great that 
patients have submitted themselves to subsequent operation for 
relief. It is questionable how much is gained by such attempts, 
as whenever adhesions are broken up new injuries are produced, 
which increase the danger of inflammation and additional adhe- 
sions. 

In all secondary operations the possibility of adhesion to the 
cicatrix should be kept in mind, and the incision should be pro- 
longed upward to obviate the danger of injuring the intestine. 

Ventral Hernia. — A weakened ventrum is not an infrequent re- 
sult of abdominal incision, and is probably its most frequent sequel. 
If neglected, a larg^ portion of the intestine may project, covered 
only by skin and integument. It is caused by defective union of 
the opposed surfaces and by the patient leaving the bed too early. 
Where a single row of sutures are used great care should be exer- 
cised to bring within the loop of the suture the entire thickness of 



614 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



the wall, especially the aponeurosis, and the patient should remain 
in bed seventeen or eighteen days. 

Probably the preferable plan of closing is to introduce a double 
row of sutures of catgut or silkworm-gut. The first row may 
include the peritoneum, muscle, and aponeurosis ; the second is 
through the skin, and drawn tight enough to oppose its cut 
edges. 

When hernia occurs the methods of overcoming its discomfort 
and progressive development are either mechanical or surgical. A 
number of pads and bandages have been used. The Marvin abdom- 
inal supporter has in our experience proved most serviceable. The 
surgical measures consist in cutting down and laying bare the apo- 
neurosis of the muscle, which is then united. 



DISEASES OF THE URETHRA, BLADDER, AND URETERS. 



Diseases of the Urethra. 

Atresia. — Atresia of the female urethra occurs as a cono-enital 
condition. It may affect the whole length of the urethra or only 
a short portion. Frequently in these cases there exists an opening 
at the umbilicus through which the fetus in intra-uterine life dis- 
charged its urine. This persists through extra-uterine life as well, 
unless an opening into the bladder below is substituted by ope- 
ration. 

If the urethra is separated from the bladder by a septum, the 
condition is best relieved after carefully establishing the position 
of the septum with the sound, by perforating it with a small trocar 
and canula, thus establishing the communication, the caliber of 
which may subsequently be enlarged. This operation can be 
more satisfactorily performed, and with less danger, in adult life. 

Frequently in a fetus having such a defect, and no avenue for 
fistulous discharge per unibilicum, the abdomen becomes distended 
to such a degree as to require puncture or the bladder may rup- 
ture spontaneously during birth. 

In hypospadias the urethral orifice lies at some point within 
the vagina: slight degrees of hypospadias often pass unnoticed. 
Where the opening is higher up, the urethral orifice is not evi- 
dent on inspecting the external genitalia, and the urine appears to 
be discharged from the vagina. 

Treatment. — Where the upper part of the urethra is perfect, 
flaps may be loosened at the sides and brought down to be approxi- 
mated in the median line. The approximation of these united flaps 
to the urethra may either be made at once or subsequently, after 
the satisfactory formation of the anterior part of the canal is assured. 
A fine needle armed with fine silk should be used. The canal 
formed should always be a little larger than it is desired the future 
canal should remain, slight contraction being allowed for. 

Dilatation. — This condition often follows unwise attempts to 



615 



616 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

explore the bladder by rapid dilatation and the introduction of the 
index finger. Permanent incontinence of urine, beyond repair, has 
repeatedly been the consequence of such injudicious treatment for 
a dysuria or has followed efforts to explore the bladder. Dilatation 
has also often been occasioned by dragging a large stone out of the 
bladder through the urethra. 

The incontinence which follows dilatation is one of the most dis- 
tressing, and at the same time most difficult, of all gynecological 
complaints to remedy. 

The serious injury seems to be at the internal urethral orifice. 
Attempts to cure it by a resection of this part of the urethra do 
not succeed in restoring continence of urine. 

Some successful efforts have been made to relieve these sufferers 
by denuding an area on each side of the external urethral orifice, 
and then passing sutures in such a way as to produce tension, lift- 
ing the posterior wall of the urethra firmly up against the anterior. 
In this way the urine is held back until the obstruction is overcome 
by a voluntary pressure from above. 

Gonorrheal Infection of the Urethra. — This condition is 
more" frequent than the few recorded observations would lead one to 
suppose. The gonococcus enters the bladder by this avenue, and 
urethritis is, therefore, one of its initial stages. 

The injected red urethral orifice is much enlarged by the pouting 
mucous membrane, whose appearance but indicates the condition of 
the remainder of the canal. A little pus may appear constantly in 
the folds of the mucous membrane, or be brought into view by 
strokino; the urethra on the vag-inal surface from the neck of the 
bladder down. Just within the orifice, or in some cases everted so 
as to be conspicuous externally, are two little orifices, one on either 
side and posteriorly, leading to Skene's glands, which run up 
parallel to the urethra for from a half to three-quarters of an 
inch. The gonococci are peculiarly prone to linger in these open- 
ings, and often, long after all trace of the disease is supposed to 
have disappeared, one or more drops of thick yellow pus can be 
squeezed out of them. 

The endoscope, which is easily used in the female urethra, shows 
that the whole canal is inflamed, and in some instances discloses 
the presence of small ulcers. 

The TREATMENT is rarely limited to the urethra alone, but 
includes the eradication of a more or less extensive gonorrheal 



DISEASES OF THE URETHRA, BLADDER, AND URETERS. 617 

infection, including that of the bladder. Appropriate general 
treatment, copaiba, etc., should be administered. Local applica- 
tions may be made of nitrate of silver, 5-10 per cent., or of 
ichthyol. It may be necessary to lay Skene's glands open in some 
old persistent cases. 

Abscess. — This is a peculiar and a rare disease of uncertain 
cause. It has been attributed to distension and ulceration of glands 
in the floor of the urethra, and to the rupture of fibres of the 
urethra with a sagging at this point, in which the ui'ine accumu- 
lates and decomposes, occasioning inflammatory changes terminating 
in abscess. The condition is recognized by a fluctuant ovoid mass 
projecting into the vagina from the anterior wall. Upon pressure, 
pus or urine mixed with pus is forced out of the urethra, and the 
sac being emptied remains flaccid for a time. 

The TEEATMENT is simple : the sac is exposed by retracting the 
posterior vaginal wall with a Sims speculum, and after being caught 
with a double tenaculum is incised for its whole length ; enough is 
then excised that the urethral canal will be left its normal size when 
the remaining flaps are brought together. 

Caruncle. — This is not a common disease. True caruncle is a 
fleshy deep-red protuberance from some portion of the urethral 
orifice, having the appearance of a raspberry or a diminutive cock's 

Fig. 351. Fig. 352. 





Caruncle attached to the Posterior Lip of the Urethral Orifice. Caruncle occluding the Urethral Orifice. 

comb. Its chief clinical peculiarity is its exquisite sensitiveness, the 
cause of which has never been adequately explained, but has been 
naturally supposed to be an unusually abundant superficial nerve- 
supply, or a denudation of the surface epithelium laying bare nerve- 
papillse. Every touch or movement causes great pain, which becomes 
agonizing in the act of micturition. In spite of this great suffer- 
ing, often reducing the patient extremely, she will sometimes 
allow years to pass before seeking relief 

Treatment. — The only proper plan is to eradicate the growth — 
if small, by the actual cautery, which may be directly applied so as 
to destroy it, when it may later be allowed to slough off. Larger 



618 ^iV^ AMERICAN TEXT-BOOK OF GYNECOLOGY. 

growths are best treated by excision, taking good care to include 
some of the tissue below the base, as after an imperfect removal 
there is usually a recurrence. The bleeding can readily be 
checked by uniting the excised area with delicate silk sutures. 
Care must be exercised not to include enough of the urethral 
orifice to narrow it considerably by the excision, thus producing 
a stricture. 

Malignant Neoplasms. — The urethra is in rare cases liable to 
invasion by malignant diseases, sarcoma and carcinoma. Sarcoma 
occurs more frequently in small children, and carcinoma in advanced 
life. Sarcomata present a livid bluish-red appearance, with a more 
or less smooth, glistening surface, projecting from the urethral 
orifice. 

The SYMPTOMS occasioned are due to the mechanical obstruc- 
tion of the urethra, rendering the voidance of urine more or less 
difficult. 

The proper treatment is immediate extirpation with the knife 
of such part of the urethra as is involved in the disease. The pro- 
cedure may prove a bloody one, but the vessels are all exposed to 
view, and can be controlled by passing ligatures around them with 
a curved needle. The more difficult cases will be those in which 
the extent of the disease is not apparent at the beginning, and in 
which the greater part of the urethra is involved. The ultimate 
result of the operation will prove futile unless the extirpation is 
carried far beyond the apparent limits of the disease. 

Carcinoma affects the urethral orifice ; it then presents a ragged, 
hard, easilv- bleeding, prominent surface. The disease may be 
extirpated in its earlier stages in the same manner as sarcoma, by 
removing the affected end of the urethra and uniting the mucous 
membrane of the canal to the vagina, establishing an urethral orifice 
higher up. 

Urethral Polyp. — This form of tumor rarely occurs in the 
urethra. It is composed of a delicately fibrillated soft, fibrous tis- 
sue, is usually reddish in color, having over its surface a net- 
work of bright-red vessels. It is usually attached by a delicate 
pedicle, and frequently hangs pendulous from the external urethral 
orifice. It is painless, and occasions at times only slight discomfort 
by partially occluding the urethra and thus rendering micturition 
difficult. 

The diagnosis is usually easy, the only conditions for which it 



DISEASES OF THE URETHRA, BLADDER, AND URETERS. 619 

may be mistaken being caruncle and prolapse of the urethral 
mucous membrane. As a caruncle is attached to the margins 
of the urethra, usually the lower, is sessile and exceedingly 
painful, there is little chance of error in this direction, while the 
rosette appearance of prolapsus with the ureteral orifice in the centre 
serves to differentiate it. 

Treatment. — The treatment consists in excision by means of 
the ecraseur or removal by strangulation with a fine silk ligature. 
It has no tendency to return after removal. 

Urethrocele. — Localized dilatation of the urethra in its middle 
third, forming a sac with a more or less constricted mouth, constitutes 
urethrocele. The upper wall of the urethra, as a rule, maintains 
its normal position, but it may sag slightly or become tortuous 
as the diverticulum enlarges. 

Fig. 353. 




G 

Urethral Diverticulum, containing pus and residual urine. 

Etiology. — Numerous causes are assigned for this condition, the 
most plausible being that of traumatism from labor or accident. 
Stricture is also said to be a cause, but as it so rarely accompanies 
urethrocele, doubt is thrown upon this statement. Englisch believes 
that it is due to the breaking of a congenital cyst of the urethral 
wall into the urethra. As this diverticulum is most frequently 
found in women who have borne children, the traumatism of labor 
must be accepted as the predominating cause in the production of 
urethrocele. 

Symptoms. — The collection and stagnation of urine in the diver- 
ticulum gives rise to great discomfort. The patient usually com- 
plains of a constant desire to urinate, which act is accompanied by 
sharp cutting pains. If the urethrocele is of much size, the urine 
which collects there is expelled when the patient coughs, laughs, 
or sneezes, or when she walks. This causes excoriation of the sur- 



620 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

rounding parts, and is productive of much mental suffering. The 
residual urine becomes ammoniacal, and occasions an urethritis 
which may extend up into the bladder and produce an obstinate 
cystitis. 

Diagnosis. — If the dilatation is marked, it may be discovered 
by digital examination through the anterior vaginal wall. The 
extent and location of the dilatation are best determined by means 
of the sound. By curving the sound and passing it, with the point 
upward, against the roof of the urethra, it glides without difficulty 
into the bladder ; but if the point be turned downward, it is at once 
arrested in the sac. Also by passing a catheter a small quantity of 
urine is obtained, first from the urethrocele, and then, when the 
instrument is introduced further and enters the bladder, there is 
a second flow of urine. 

Teeatment. — The best plan of treatment is that of Bozeman, 
who makes an opening in the anterior vaginal wall in the most 
dependent part of the sac. By this means free drainage is secured, 
and the inflamed tissue is permitted to resume its normal condition, 
when a plastic operation can be performed for the restoration of the 
urethra to its normal caliber. 

Stricture. — Organic stricture of the urethra is of rare occur- 
rence, as the normal caliber of this canal is such that even if there 
be a slight narrowing in its course, the symptoms are so insig- 
nificant as to give rise to no discomfort. It is only in those cases 
where there is marked cicatricial contraction that this condition calls 
for treatment. Strictures of large caliber, as described by Skene, 
have a problematic existence. 

Traumatism, especially from labor, gonorrheal urethritis, syphilis, 
and very rarely tuberculosis, may cause stricture. The applications 
of nitric acid, corrosive sublimate, and other caustics are also reported 
as causal agents. 

In vesico- vaginal fistula of long standing there is often functional 
atrophy of the muscular coats of the urethra from disuse, resulting 
in a general narrowing of its caliber. 

SYMPTOMS.^Frequent and difficult micturition, gradually increas- 
ing, is the chief symptom of stricture. In rare cases there is 
incontinence, while in others there may be infrequent micturition, 
at times approaching retention. In cases of long standing dilata- 
tion of the bladder or cystitis may result. According to Skene, the 



DISEASES OF THE UBETHBA, BLADDER, AND UBETEBS, 621 

symptoms of stricture at the vesical end of the urethra are out of 
all pi'oportion to the lesion. 

Diagnosis. — As the symptoms are not sufficiently suggestive, the 
urethra should always be examined. A vaginal examination usually 
shows thickening at some part on the anterior wall corresponding to 
the course of the urethra. If a sound be introduced, it will meet with 
resistance at this point, and it may not be possible to pass it farther. 
The diagnosis is not difficult, and is made by means of the sound 
and by vaginal examination. 

Peognosis. — In all cases of short duration the prognosis is 
favorable. Only where cystitis or dilatation of the bladder coex- 
ists should the prognosis be guarded. 

Treatment. — Gradual dilatation should be practised by means 
of Hegar's dilators, starting with one of the small sizes and grad- 
ually leading up to a No. 15. Care should be used not to rupture 
the urethra by too rapid dilatations, as incontinence may result 
from such an accident. Very rarely when the cicatricial tissue is 
dense and unyielding, division of the stricture according to Ottis's 
method in stricture in the male may be required. 

Prolapse. — Prolapse or ectropion of the urethral mucous mem- 
brane is not infrequently found in female children, but is of rare 
occurrence in women. Vesical calculus, urethritis, rectal irritation 
as from fissure, hemorrhoids, or prolapsus, and in children irritation 
from intestinal parasites, especially ascarides, are frequently asso- 
ciated with, and usually responsible for, prolapse of the urethra. 

Symptoms. — Frequent and painful micturition and tenderness 
about the urethral triangle are the chief symptoms. It is also fre- 
quently attended with painful coitus, and may interfere with 
walking. 

Diagnosis. — As the symptoms are not diagnostic, a visual exam- 
ination is necessary. The prolapsed portion of the urethral mucous 
membrane encircles the mouth of the urethra, and may present the 
appearance of a rosette. The urethral opening in the centre is cha- 
racteristic, and differentiates this condition from caruncle or other 
tumors. The urethral fold, if oedematous or swollen, may not be 
replaced, but, as a rule, when the patient is placed in the lithotomy 
position and slight manipulation is made, the mucous membrane at 
once disappears within the urethra. If the prolapsus is of long 
standing, the mucous membrane may present a glazed, dry, or 
excoriated surface. 



622 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

Treatment. — In recent cases, especially in children, after the 
prolapsed membrane is replaced the patient should remain in bed 
in the recumbent position for a few days. In the mean time 
astringent urethral suppositories composed of tannin, or topical 
applications of dilute carbolic acid or iodine, may assist in retaining 
the mucous membrane in situ by taking up the lax tissue. 

The bladder should be carefully explored for stone, tumors, or 
polyps. The bowels should be kept loose, as straining at stool 
always increases the prolapsus. If the condition is persistent and 
does not yield to local treatment, the redundant mucous membrane 
should be excised, and the external or vaginal and the urethral 
mucous membrane brought together by radiating sutures of fine 
silk. The galvano- or Paquelin's cautery may be used for the 
same purpose. 

If there is great redundancy of the mucous membrane, Emmet's 
buttonhole operation may be resorted to. By this method a hole is 
made in the urethro- vaginal septum, and the urethral mucous mem- 
brane is drawn through until the prolapsed portion is returned into 
the urethra, when it is stitched in the angles of the wound and 
snipped off. The fistula may be closed at the same sitting, or later 
if drainage is desirable. 

Diseases of the Bladder. 

Congenital Malformations of the Bladder. — The bladder 
is subject to a great number of deformities due to embryological 
deviations, but, fortunately, they are of rare occurrence. 

In some cases the bladder is bipartite, with two cavities partially 
or completely separated by a septum. These cavities may lie side 
by side or one above the other, the ureters opening into one or both. 
Blasius has reported a case in which the bladder was divided into 
five compartments. 

Two or more bladders are said to coexist in some instances, but 
in the larger number of reported cases the condition is probably due 
to extreme sacculation as the result of disease or from displacement 
caused by the pressure of neighboring organs. Thus in prolapsus 
uteri a diverticulum may be found in the bladder which on super- 
ficial examination might suggest two bladders. Demandie suggests 
that the so-called supernumerary bladder may be the pouch of a 
dilated urachus, and reports a case in support of this statement. It 
is possible for a congenital cyst in close proximity to the bladder to 



DISEASES OF THE URETHRA, BLADDER, AND URETERS. 623 

simulate a supernumerary bladder. Cases are reported in which the 
bladder was absent and the ureter emptied into the rectum, vagina, 
or urethra. Merckel, Fleury, Oliver, and Blasius each have reported 
cases in which the ureters emptied into the urethra. 

A patulous urachus may exist as a canal of small caliber leading 
from the bladder to the umbilicus, or it may be distended in one or 
more places as a cyst. Urine may be discharged from the umbili- 
cus through the urachus. In one case which has been recorded the 
umbilicus communicated with the bladder. An arrest in develop- 
ment may leave the bladder as a small pear-shaped organ, or there 
may be a congenital dilatation either uniform or localized. 

Thus it will be seen from these few cases that the bladder is 
subject to various anomalies. The complicated embryological de- 
velopment of the genito-urinary organs renders them liable to many 
deformities. 

By far the most frequent of the congenital defects of this viscus is 

Extroversion or Extrophy of the Bladder. 

This anomaly is far more frequent in the male than in the female 
sex. It consists in the absence of the anterior walls of the bladder, 
of the corresponding part of the anterior abdominal wall, and often of 
the symphysis pubis. The clitoris is slit into two portions, the ante- 
rior commissure of the vulva is absent, and the bladder opens directly 
into the vagina. The vagina may be normal or appear as an elon- 
gated transverse fissure. As the uterus and its appendages are 
usually normal, extrophy of the bladder is not incompatible with 
childbearing. The vaginal orifice may even be occluded with a 
hymen. This deformity is not detrimental to long life. The de- 
ficiency in the abdominal parietes may be slight or extensive, 
depending upon the distance above the symphysis at which the 
diastasis occurs, and also upon the degree of separation betw^eefi the 
pubic bones. The separation in the abdominal muscles may occur 
above the usual site of the umbilicus, which is absent in such cases, 
or it may take place lower down, the fibres of these muscles run- 
ning out to their point of insertion, leaving a triangular opening in 
the abdominal wall. The space between the pubic bones may be 
slio'ht or extensive, and is either filled in with fibrous tissue or exists 
as an unobstructed opening. The bladder is pushed forward by the 
viscera crowding down upon its posterior wall, and pouts out as a 
spongy, red-looking surface. The continual irritation of the cloth- 



624 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

ing and exposure to the air, causing a deposit of urinary salts, keep 
the raucous membrane constantly inflamed. The slightest trauma- 
tism causes bleeding. The orifices of the ureter can usually be 
seen, and are often dilated. The urine is always escaping, and 
if great cleanliness is not observed the surrounding parts become 
inflamed and excoriated. Even with the greatest care such a con- 
dition may arise. 

Treatment. — The treatment of this anomaly is a subject of no 
little importance, from the great distress occasioned by the constant 
dribbling of the urine and the excoriation of the parts. In all cases 
the treatment, whether operative or mechanical, is only palliative, as 
the function of the bladder cannot be completely restored. Various- 
mechanical devices have been employed for conducting the urine 
away from the bladder, but they are usually unsatisfactory. The 
repair of the defect by a plastic operation should always be at- 
tempted. On account of the impossibility of keeping the field 
aseptic failure is frequent, and many operations may be required 
to accomplish the result desired. 

A number of ingenious operations have been devised for extro- 
phy of the bladder, but those employing a central flap made from 
above with lateral flaps appear to us to be the most advisable. 
Thiersch's operation embraces these principles, and is frequently 
successful. The deformity in the urethra should be first corrected 
before the vesical defect is repaired. 

The method as devised by Thiersch consists, first,' in the lifting 
up of a flap from the centre of the abdomen above the opening. 
This flap should be of sufficient size to close in the bladder, and 
must have a pedicle. The edges of the abdominal opening are 
freshened, and the flap is brought down in such a way as to throw 
the skin-surface against the mucous membrane of the bladder. 
The margins of the flap are thus stitched to the denuded edges of 
the abdominal opening. Bridge-like flaps are dissected up from the 
inguinal regions on either side of the opening, leaving both ends 
attached. Iodoform gauze is packed beneath these flaps until gran- 
ulations spring up and the nutrition of the parts is well established, 
when the upper ends may be cut and the flaps pushed over upon the 
granulating surface of the central flap and secured in place by 
suture. In this way the first flap is reinforced and the lateral 
edges of the denuded opening are protected. In all cases there will 
be incontinence of urine, as the sphincter muscles are absent, and so 



DISEASES OF THE URETHRA, BLADDER, AND URETERS, 625 

far no method of treatment has been advanced to replace their func- 
tion. For this reason some form of ambulatory urinal is required. 
The great advantage of this operation is that the constant drib- 
bling of urine over the thighs, genitals, and buttocks is obviated. 
Thiersch, in order to do away with the necessity of using a urinal 
in women, has established an artificial channel from the bladder to 
the rectum. This, however, is not advisable, as the rectum is not 
tolerant to urine, and if it lose its function the condition of the 
patient is more deplorable than in the beginning. Billroth advises 
making a small fistula through the central flap, as the recti muscles 
ofteii close the opening sufficiently to retain urine. 

If the skin extends slowly toward the centre of the flaps, trans- 
plantation should be employed to hasten this process. Trendelenberg 
divides the symphysis pubis, if united, and causes the ends to over- 
lap by means of a plaster cast. In this way the separated parietes 
are brought into apposition by causing a contracted pelvis. He 
then freshens the edges and brings them together with strong 
sutures. Czerny closes the opening by detaching the vesical 
mucous membrane, leaving a small area as an avenue for nutri- 
tion, and unites the edges in the central line, thus restoring the 
mucous lining of the bladder ; he then reinforces this mucous 
layer by means of lateral bridge-flaps. 

Preceding operations for the restoration of extroversion of the 
bladder, the surrounding parts must be restored to a healthy con- 
dition by the liberal use of zinc-oxide ointment. The urine should 
be kept bland by the use of proper drugs if the alkalinity is so 
marked as to produce irritation. The general nutrition of the 
patient should be carefully looked into and no operative measure 
instituted before she is in good health. If the operation be suc- 
cessful, some form of ambulatory urinal may be prescribed, and the 
patient is able to live much more comfortably, as the excoriation 
and inflammation of surrounding parts, the disgusting odor, and 
constant dribbling of urine, are obviated. 

Irritable Bladder. — Under this heading are grouped those 
etiological factors, either intrinsic or extrinsic to the bladder, which 
are not sufficient to induce organic disease of this organ, but which 
keep it in a constant state of irritability. 

The SYMPTOMS at times are such as to lead to a diagnosis of 
cystitis. A careful examination, however, shows the bladder to be 
apparently normal, and we are forced to ascribe the symptoms to 

40 



626 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

simple irritation of the peripheral nerves, either from direct or 
reflex causes. 

Probably the most painful form of irritable bladder is that fol- 
lowing plastic or abdominal operations, especially the latter. In 
many abdominal-section cases the symptoms of irritation so closely 
simulate those of cystitis as to lead to the latter diagnosis. 

In all gynecological cases a careful chemical and microscopical 
examination of the urine should be made before operation, as we 
then have a control test by which future examinations may be com- 
pared. Following coeliotomy, the urine is generally of high specific 
gravity, has a heavy sediment, consisting usually of amorphous urates 
and phosphatic crystals, and is capable of producing great vesical 
irritability, if not a light grade of cystitis. 

Patients frequently complain of vesical disorders, especially pain- 
ful micturition, for two to five days following operation, and it will 
be noted that as the urine decreases in specific gravity, and as the 
heavy sediment disappears, the symptoms of irritation have also 
gradually decreased, and by the time the urine has reached the 
normal these have entirely disappeared. Under these circum- 
stances the term " irritable bladder " is the most expressive, as the 
symptoms of cystitis are not so fleeting in character. In these 
cases the frequent and painful micturition must be ascribed to 
direct chemical irritation from the heavily-charged urine. 

The quantity of urine is frequently so much decreased follow^- 
ing operations as to suggest suppression from nephritis or obstruc- 
tion of one or both ureters ; but it will be found, if the urine be 
measured from day to day, that the quantity increases in an ascend- 
ing ratio until about the tenth day, when it again reaches the 
normal. It will thus be seen that for at least five days there is 
ample cause for irritability of the bladder from the concentrated 
urine. 

Again, the highly alkaline urine of pyonephrosis and other 
kidney affections, along with acrid pus, which is often found in 
these cases, may cause great irritation, which soon runs into cystitis 
if the cause is not removed. 

Another factor in the production of this condition in a certain 
number of operation cases is probably that of reflex sympathetic 
irritation. In pelvic inflammatory disease in which the uterine 
appendages are densely adherent, and require considerable force to 
enucleate them, or where a tumor is extensively adherent, there 



DISEASES OF THE UBETHBA, BLADDER, AND UBETEBS. 627 

must be more or less irritability of the bladder from mere con- 
tiguity. 

During pregnancy there is frequently a functional irritability, 
especially in hyperesthetic individuals, from pressure of the gravid 
womb. This may occur in any month of pregnancy, and is fre- 
quently very annoying. The same condition may arise during the 
growth of a myoma or other large tumor. 

Dislocations of the bladder give rise to irritability, as, for instance, 
in cystocele accompanying prolapsus uteri ; here it is due frequently 
to the deposition of urinary salts in the diverticulum, and often runs 
into chronic cystitis. 

It is not uncommon for the bladder to be adherent to pelvic 
tumors, which, as they increase in size, drag the organ upward 
and increase the tension on the vesical neck, thus causing frequent 
and painful micturition. 

Hysteria also has as one of its innumerable symptoms irritability 
of the bladder, which may be so marked as to lead to urinary in- 
continence or spasmodic retention. 

Urethral caruncle, carcinoma of adjacent organs, prolapsus of the 
rectum, fissure in ano, rectal ulcer, and hemorrhoids may give rise 
reflexly to irritability of the bladder. Excessive venery is also said 
to be a cause. Various emotional disturbances, such as grief, joy, 
and pain, may also act as etiological factors in this condition. 

Frequently in disease of the ureters the symptoms of irritable 
bladder are so marked as to mask the true condition. 

Of all inflammatory diseases of the uterus and its appendages 
one of the most annoying symptoms is painful micturition. In 
these cases during life the cystoscope reveals no change in the ves- 
ical mucous membrane, and if such a case comes to autopsy a 
careful pathological examination shows the vesical mucous mem- 
brane to be normal. The most rational explanation of these 
phenomena in such cases is that of reflex irritability from con- 
tiguity of the organs. 

Symptoms. — The symptoms frequently so closely simulate those 
of cystitis as to lead to that diagnosis if a urinary examination is not 
made. There may be frequent and painful micturition, at times even 
strangury ; dull, heavy pains over the pubes, radiating upward into 
the loins and downward into the thighs and external genitalia. In 
other cases there may be a spasmodic condition of the sphincter 
vesicae, causing complete retention. Incontinence may be present 



628 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

in some cases. In post-operative irritability of the bladder the 
urine is very characteristic. In irritability due to pregnancy, press- 
ure from tumors, reflex causes, etc. the urine is very different from 
the above. 

Diagnosis. — Upon the urinary examination depends the dia- 
gnosis. In simple irritability following operation the specific 
gravity of the urine is rarely less than 1020, and may be as high 
as 1040 ; the acidity is usually marked ; the color is high, and on 
standing the urine deposits a heavy reddish or reddish-yellow sedi- 
ment, which usually disappears on boiling. The chemical exam- 
ination shows no albumen or at most only a slight trace. The mi- 
croscopic examination reveals a field heavily laden with amorphous 
urates or phosphatic crystals. 

Upon the absence of pus and bladder epithelium depends the 
diagnosis of irritability. In the clear limpid urine of low specific 
gravity the microscopic examination is usually negative. 

In the early stage of cystitis, when there is only congestion of 
the mucous membrane, before the leucocytes have wandered from 
the vessels, no pus will be observed on microscopic examination, and 
at this stage a differential diagnosis between irritability and inflam- 
mation of the bladder is not possible. For this reason when there 
are symptoms of irritability the urine should be examined at least 
every twenty-four hours until pus is found or excluded. 

Treatment. — ^As the treatment must be largely directed toward 
the cause, each case will be a law unto itself, and may require special 
treatment. 

In' operative cases, if the symptoms are severe, the bladder should 
be frequently catheterized to prevent the accumulation of heavily- 
charged urine. In exceptional cases irrigation may be resorted to 
especially if there is fear of cystitis. As soon as the patient recov- 
ers from the nausea following the anesthesia a mild diuretic, such 
as liquor potassii citratis or spt. setheris nitrosi, may be adminis- 
tered. The following combination of these drugs is often of 
service : 

15^. Spt. aether, nitrosi, fij ; 

Liq. potas. citratis, q. s. f^iv. — M. 

Sig. Dessertspoonful every four hours. 

This increases the urinary excretion and renders the urine more 
bland. 



DISEASES OF THE UBETHBA, BLADDER, AND UBETEBS, 629 

When the gravid uterus is responsible for the irritability, little 
can be done unless this organ is in malposition, when it can be 
replaced. 

In hysterical irritability there is frequently retention of urine 
instead of too frequent micturition. In these cases all measures 
should be resorted to before that of catheterization, as the so-called 
" catheter habit " may be easily established in neurotic women. 

When the irritability is due to reflex causes, no treatment is of 
value except that directed toward the removal of the cause ; thus in 
urethral caruncle, fissure in ano, etc. treatment directed to the vesical 
symptoms would be valueless. 

In nervous women the bromide salts may be given in small doses, 
and often act well in allaying the irritability. When there is 
exposure of the vesical sphincter, accompanied with great pain and 
retention, it may be necessary to resort to opiates or chloral. A 
rectal enema of starch-water with ten drops of the tincture of opium 
often gives immediate relief. In some cases rectal injections of hot 
water serve as well in overcoming this spasmodic condition. Hot 
applications over the vesical area often are of value. Belladonna 
suppositories are also recommended, and seem to do good in those 
cases of irritability due to reflex causes. Diluent fluids and pure 
water should be liberally injected. 

Cystitis. — Inflammation of the bladder occurs either as an acute 
or a chronic process. 

Etiology. — The most frequent cause of cystitis is the introduc- 
tion of septic matter into the bladder by means of catheters, 
bougies, or other instruments. The gonococcus may also be the 
infecting agent, gaining access through the urethra from the 
inflamed vagina. 

From motives of delicacy women often fail to empty the bladder 
when travelling or in public places, and as a result a severe cystitis 
is induced by over-distension. Other frequent causes of inflam- 
mation of the bladder are pathological changes in the urine from 
fermentation or excessive excretion of urinary salts. Skene believes 
that no abnormality of the urine will excite acute inflammation in 
the healthy bladder, but believes that a previously diseased mucous 
membrane must exist before abnormal urine can give rise to cystitis. 

A number of other writers, however, hold that decomposing 
urine is of itself sufiicient to excite the inflammatory process. 
Traumatism from labor or other sources, as kicks or blows, may 



630 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

induce a violent cystitis, especially if the bladder be distended with 
urine. 

In labor, during the passage of the child's head, the urethra may 
be bruised against the symphysis pubis, and later the mucous mem- 
brane swells, occluding the urethral canal, and thus causes reten- 
tion of urine. In such cases the bladder may be greatly distended, 
but the constant dribbling of urine causes the nurse or doctor to 
regard it as only a temporary incontinence, and as a result a severe 
cystitis arises before the cause is discovered. Foreign bodies, tumors, 
and calculi are all provocative of cystitis. 

Inflammation of the bladder is also occasionally the result of a 
direct extension from some neighboring organs, as in salpingitis, 
vaginitis, pelvic abscess, carcinoma of the vagina, uterus, or rectum, 
pyonephrosis, ureteritis, peritonitis, etc. 

Chemical irritation from the ingestion or local application of 
cantharides or turpentine or the use of ethereal oils is also a rare 
cause of this disease. Injections of strong solutions of silver nitrate 
and other drugs may cause a severe inflammation. 

Pathology. — In the early stage of an acute cystitis the mucous 
membrane is red and congested, but is otherwise normal ; later the 
changes are marked, the walls of the bladder becoming thickened 
and the mucous surface covered with pus, fibrin, and exfoliated 
epithelium. Small bleeding areas where the epithelium has become 
detached are often seen. 

In the chronic process the pathological changes are still more 
extensive. The muscular and fibrous coats are greatly hypertrophied, 
and the actual cavity of the bladder is much decreased by the thick- 
ening and contraction of its walls. The rugse stand out as promi- 
nent ridges and may assume a polypoid form. 

Hemorrhage occurs into the mucous membrane, and appears as 
dark ecchymotic patches, which later change to slate-color as the 
extravasated blood is absorbed, leaving only the coloring matter 
in the tissues as a more or less permanent stain. As a rule, when 
the cystitis arises as a result of over-distension the bladder-walls 
will be thin and parchment-like. In these cases the diphtheritic 
or croupous type of inflammation is most likely to occur. The 
entire mucous membrane is extensivelv involved, and is covered 
with a layer of fibrinous material or false membrane, which may be 
thrown ofl* as a complete cast of the interior of the bladder. 

In the more severe cases of diphtheritic cystitis this membrane 



DISEASES OF THE VRETHBA, BLADDER, AND UBETEBS. 631 

is composed not only of necrotic mucous membrane, but also at 
times the muscular coat is included. It has been stated that por- 
tions of the peritoneal covering of the bladder have been included 
in these casts. Where there is such extensive inflammation of the 
bladder the surrounding organs are more or less involved through 
extension by continuity, and are closely adherent to one another. 

In some cases the diphtheritic process becomes localized, and 
deep erosions or ragged ulcers result. These ulcerated areas may 
only involve the mucous coat, or may extend deeper and attack the 
muscular coat, and in rare instances perforate the bladder-wall. 

The urine is usually intensely alkaline and heavily laden with 
mucus and with urinary salts, especially the phosphatic. These 
salts are often deposited as fine incrustations on the ulcerated areas. 

When voided the urine may be of a reddish or brownish or 
milky color, and if allowed to stand for a few hours in a conical 
glass, a thick yellowish or reddish sediment settles to the bottom, 
while the top is clear, or if bacteria be present it will usually be 
very turbid. On examining such a specimen microscopically there 
will be found a large number of leucocytes or red corpuscles, pave- 
ment epithelium, isolated or in clumps, and often large numbers of 
crystals of triple phosphates. If the urine has undergone fermen- 
tation either within or outside the bladder, myriads of an actively 
motile bacterium will be seen. 

The worst forms of diphtheritic cystitis may merge into gangrene 
and the whole bladder be involved in a putrid sloughing mass. 
Rokitansky has described a peculiar ulcer of the bladder which he 
thinks is analogous to the round ulcer of the stomach. 

As a result of the hypertrophic thickening of the bladder-walls 
the vesical orifices of the urethra may be partially occluded, and 
dilatation of the ureters, pyonephrosis, or hydronephrosis may 
occur. 

Symptoms. — In no condition is the pain more agonizing than in 
an acute or ulcerative cystitis. The pain is usually most severe 
above and behind the pubes, radiating into the groin and down the 
thighs. If able to be about, the patient walks very slowly and the 
body is slightly inclined forward ; if in bed, the legs are usually 
flexed upon the abdomen, as the slightest jar or tension on the 
abdominal muscle increases the pain. The desire to void the urine 
is constant, and the act is attended with sharp lancinating pains at 
the base of the bladder, which decrease after the urine is voided. A 



632 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

few drops of blood may be ejected with the urine. There is usually 
constant dull pain over the pubes, which increases as the bladder is 
distended with urine. 

Pressure over the pubes causes great pain, and at times the ten- 
derness in the region is so marked that even the weight of the bed- 
clothing cannot be borne. Following urination there is usually a 
sensation as though a few drops of urine yet remained, which gives 
rise to constant bearing-down pains for hours after. These pains 
may be so urgent as to cause the patient to remain for hours on the 
chamber, and may cause her to scream out with agony. There is 
often dull pain in the perineum, and occasionally a patient describes 
peculiar sensations about the umbilicus. 

Increased frequency of micturition is an invariable symptom in 
cystitis, in acute cases the desire being constant ; in milder cases less 
frequent, but always urgent. 

Hematuria is frequent in the early stage of the inflammation, and 
at times there may be little else than pure blood voided. As the 
process becomes older the blood in the urine diminishes, and may 
entirely disappear. The appearance of the urine, which has been 
described above, is also characteristic. If micro-organisms have 
gained access to the bladder, fermentation of the urine results, and 
the odor of the recently-voided specimen is excessively ammoniacal 
and fetid. In acute or ulcerative cystitis defecation may be paniful 
and menstruation is often deranged. In acute cases the attack is ush- 
ered in by a rigor, followed by a slight increase in temperature and 
sharp pain in the region of the bladder. If of the milder type of 
cystitis, a few days sufiice to free the patient from all discomfort. 

In the more severe septic or diphtheritic cases the symptoms from 
the onset indicate a very grave condition. The temperature ranges 
between 101° and 103° F. ; the rigors are severe and occur at inter- 
vals for days ; the tongue becomes dry, glazed, and coated, and may 
be fissured; there are headache and vomiting, and occasionally de- 
lirium. Micturition is difficult and excessively painful, and may be 
impossible on account of the occlusion of the ureteral orifice with 
false membrane. If the bladder is catheterized, only a small amount 
of urine can be drawn without cleansing the catheter of shreds of 
membrane. 

The bladder may become greatly distended on account of reten- 
tion. The urine has an excessively fetid odor and is of a brownish 
or reddish color. Large pieces of membrane, and at times a com- 



DISEASES OF THE URETHRA, BLADDER, AND URETERS. 633 

plete cast of the interior of the bladder, may be expelled through 
the urethra. 

The patient sinks into a typhoid state ; the pulse becomes rapid, 
running, and feeble ; the temperature gradually rises during the day, 
reaching its highest point in the evening ; there may be carphologia 
and subsultus, and she finally goes into profound collapse and dies. 

As the kidneys are often much hindered in their action because 
of the vesical disorder, there may be total suppression of urine, fol- 
lowed by uremia, from which she dies. 

Diagnosis. — The dull heavy pain over the pubes, the sharp lan- 
cinating pain during micturition, the frequent desire to void the 
urine, are all subjective symptoms strongly indicative of cystitis. 

In the irritable bladder due to inflammation of neighboring 
organs or to a uterus in malposition, the symptoms may closely 
resemble those of cystitis, but in such cases an examination of the 
urine will at once exclude cystitis, as in irritable bladder from reflex 
or other causes the urine is most likely to be clear and limpid, and 
on microscopic examination no pus or epithelial cells are found. 

The urine of cystitis is characteristic, and a diagnosis can usually 
be made from a microscopic examination. A recently voided spe- 
cimen appears turbid, and if the inflammation is acute it may be 
tinged with red. On standing a thick tenacious yellow sediment 
forms at the bottom of the vessel, and if red corpuscles be present a 
thin reddish strata is observed superimposed upon the lower or yel- 
lowish strata ; above this the urine may be clear or slightly turbid. 
The specific gravity is valueless as a point in the diagnosis, as it 
may range between 1010 and 1030. On pouring the urine, after 
standing for a few hours, from one vessel to another, the sediment 
may be so tenacious as to adhere closely to the bottom. Albumen 
is found in varying quantity, depending upon the amount of pus 
present. If the inflammation is acute, the reaction is usually acid ; 
but if chronic, it will in the larger proportion of cases be neutral or 
alkaline. On microscopic examination the field is filled with pus- 
cells, pavement epithelium, isolated or in clumps, and in the acute 
cases red blood-corpuscles. Fine strands of mucus are often seen 
in which pus and red corpuscles are entangled. In the chronic 
forms of cystitis a large number of crystals, usually of the phos- 
phatic salts, are often observed. 

The urine may be excessively fetid and ammoniacal when voided, 
due to the introduction of bacteria into the bladder. ' 



634 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

In those cases in which epithelium from the ureter and pelvis of 
the kidney are found, the ureteral catheters should be employed to 
establish the diagnosis, to determine definitely the extent of the 
inflammation in these organs, and whether only one or both ureters 
and kidneys are affected. If a vesical calculus or tumor be sus- 
pected, the sound or cystoscope should be employed. 

In diphtheritic cystitis the constitutional symptoms, in conjunc- 
tion with the odor of the urine, which becomes excessively fetid, 
are usually sufficient to indicate the character of the inflammation. 

Prognosis. — In the milder forms of acute cystitis arising in the 
course of pregnancy, or as the result of chemical or mechanical 
causes, or from slight infection, the duration will usually be from 
five to ten days. The prognosis as to the duration of cystitis always 
depends upon the cause, and until this is definitely settled it is not 
advisable to make any statement with regard to the time of recovery. 

Chronic cystitis is always intractable, and may last for years even 
under the most skillful treatment. 

In diphtheritic inflammation and gangrene of the bladder naught 
but an unfavorable prognosis can be given, as these conditions are 
always exceedingly grave and treatment is of but little avail. 

Treatment. — As a large proportion of cases of cystitis arise 
from the introduction of pyogenic organisms into the bladder, too 
great care cannot be exercised in the cleansing and sterilization of 
all instruments to be introduced into the bladder. 

The mere sterilization of these instruments is not sufficient to 
prevent contamination, as recent bacteriological investigations 
demonstrate a large number of organisms, both pyogenic and 
non-pyogenic, in the vagina and about the urethral orifice ; un- 
less the external genitalia be carefully cleansed there is constant 
danger of infection from these parts. A glass catheter with 
smoothed ends should always be employed if available, as those 
made of rubber and metal are much more difficult to sterilize. 

Each patient should have her own catheter, and in hospital 
practice it is a good plan to have a bottle labeled with the patient's 
name, in which the instrument is kept. 

Before use the catheter should be boiled for at least five minutes, 
and transferred to a bottle containing a 5 per cent, carbolic-acid 
solution. The external genitals, especially about the urethral ori- 
fice, should be carefully washed with a saturated solution of boracic 
acid before catheterization, which is best applied with a pledget 



DISEASES OF THE URETHRA, BLADDER, AND URETERS, 635 

of cotton on the end of application forceps. In this way the nurse, 
who may have come from a septic case or whose hands may be con- 
taminated, avoids all risJi of infecting the bladder. The labia are 
separated with the thumb and forefinger of one hand, care being 
used not to touch the parts near the urethra, and the catheter in- 
serted. Before removing the catheter the finger should be placed 
over the end, and thus prevent the urine from escaping over the 
parts when it is withdraw^n. It should be at once cleansed in boil- 
ing water and placed in its receptacle. If this routine be followed, 
cystitis during the puerperium or after operation will rarely arise. 
If a rubber catheter be used, it should be opened at the end, as it 
is very difiicult, if not impossible, to cleanse one which has a closed 
end with eyes on the sides. Operative and puerperal cases should 
be carefully watched to prevent retention, and the patient's w^ord 
must not be taken with regard to the voidance of her urine, as from 
motives of delicacy or from ignorance she may not inform the 
physician of her urinary troubles. 

The first requisite in the treatment of cystitis is rest, and to 
accomplish this the patient must at once go to bed and lie in the 
recumbent position. All stimulating foods, such as meats, highly- 
seasoned dishes, alcoholic beverages, especially those containing a 
large percentage of alcohol, should be avoided. It is best to restrict 
the diet to milk or light broths. Saline cathartics should be admin- 
istered, and later care must be used to keep the lower bowel free from 
fecal accumulation. Warm enemata are useful, not only as a means 
of evacuating the bowel, but also as a soothing agent. Hot sitz- 
baths usually relieve the tenesmus and vesical fullness. If the pain 
is severe, an enema of 30 drops of tincture of opium in 2 ounces 
of starch- water may be employed, or opium may be given in sup- 
pository. Sometimes an iodoform or belladonna suppository will 
relieve the pain. Hot compresses should be applied over the 
bladder. Cups applied to the sacrum are often useful in relieving 
tenesmus and the sensation of fullness. 

To allay the fever and keep the urine bland and unirritating the 
following prescription will prove of value : 

^. Tinct. aconiti, fsj ; 

Spirit, aether, nitrosi, ' f^ij ; 

Liquor potassii citratis, q. s. ad f3vj. — M. 

Sig. A dessertspoonful every four hours. 



636 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

Benzoate of ammonia, in the dose of gr. x every two hours, has 
been highly recommended. 

In acute cases which are of septic origin irrigations of the bladder 
should be at once instituted, as the removal of the infecting agent is 
of prime importance. 

The solutions used in washing out the bladder are numerous, but 
those which have been of greatest value are boracic acid (50 per 
cent, to saturated solution), weak solutions of permanganate of 
potash, bichloride of mercury (1 : 10,000), and silver nitrate (1 to 4 
gr. to the ounce). 

The following is the best manner for irrigating the bladder : A 
glass catheter should be attached to an ordinary or fountain 
syringe by means of a rubber tubing or small soft-rubber catheter. 
The temperature of the water should be 100° to 105° F. The same 
precautions in cleansing the external genitals should be observed in 
irrigations as in catheterization. The patient lies in a recumbent 
position with the hips slightly elevated, resting on a bed-pan. The 
solution is allowed to flow before introduction of the catheter, when 
the rubber tube is pinched up, thus preventing the introduction of 
air into the bladder. A sufficient quantity of the solution is per- 
mitted to flow into the bladder until slight distension is produced 
or the patient complains of pain. The fluid is allowed to remain 
for a few seconds, when it is withdrawn by detaching the rubber 
tubing from the catheter. The irrigations should be repeated until 
the fluid flows away clear. At first the patient will probably not be 
able to stand more than one irrigation daily, but after one or two 
days she becomes accustomed to the treatment, and if the case is 
badly infected, the bladder can be washed out thrice daily. Boracic 
acid is always the best solution to commence with, as it is free from 
danger and is less irritating than bichloride of mercury or silver 
nitrate. Repeated hot vaginal douches are very beneficial. 

The treatment of chronic cystitis differs in many respects from 
that of the acute inflammation. The mucous membrane of the 
bladder, instead of being functionally over-active as in the acute 
form, is depraved and its function largely destroyed by the chronic 
inflammation. For this reason stimulating injections and internal 
remedies must be employed with the hope of bringing into activity 
the depraved mucous membrane. It is in these cases that the solu- 
tions of bichloride of mercury and silver nitrate will be of greatest 
service. More than two irrigations daily with these solutions should 



I 



DISEASES OF THE URETHRA, BLADDER, AND URETERS, 637 

never be given. If the pain after the employment of silver nitrate 
is excessive, a 5 per cent, salt solution may be injected, which pre- 
cipitates the silver nitrate in the form of an unirritating chloride 
of silver. 

The reaction of the urine must be carefully noted, and if decidedly 
alkaline or acid, remedies should be employed to neutralize or make 
it of the opposite reaction. Within the last year iodoform in the 
form of an emulsion (50.0 iodoform ; 40.0 glycerin ; aq. destillat. 
10.0 ; mucilago acacise q. s.) has been highly recommended as an 
injection, and should be tried if the solutions just advised fail to 
relieve the patient. Resorcin solution (2 per cent.) may also be 
employed in obstinate cases. Benzoic or boracic acid, in the dose of 
ten grains made up in pill form with glycerin, is the best drug for 
converting an alkaline into an acid urine. Citrate of potassium is 
one of the best remedies to be employed when the urine is acid. 

If, as in many cases, the treatment fails and the pathological 
process grows worse, it may be necessary to secure constant drain- 
age of the bladder by means of dilatation of the urethra, by vesico- 
vaginal fistula, or by the use of a self-retaining catheter. 

Dilatation of the urethra may relieve the tenesmus and secure 
drainage for a short time, but at best is but a temporary measure, 
and must be repeated a number of times if it is to be of value ; for 
this reason it is not, as a rule, practicable. It may be accomplished 
either gradually by the use of a hard-rubber graduated bougie or 
rapidly by the aid of Goodell's small uterine dilator. The danger 
of urinary incontinence must always be borne in mind, as over- 
dilatation may result in permanent incontinence. The use of a 
self-retaining catheter is only to be employed when operative 
measures are refused. 

The best plan is drainage through a vesico-vaginal fistula. 
Emmet advises the opening to be made as follows : " The patient 
is etherized and placed in the Sims position, and the perineum well 
retracted ; a sharply-curved sound is passed into the bladder and 
its beak pressed against the septum, so as to protrude in the median 
line a short distance behind the vesical orifice : it is then cut down 
upon by the aid of tenaculum and scissors. The blunt blade of 
the latter is inserted through the opening into the bladder, and the 
incision prolonged 3 or 4 cm. in the direction of the cervix uteri. 
Care must be taken that the blade of the scissors really enters the 
bladder, since it is apt to penetrate the loose cellular tissue between 



638 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the vesical and vaginal membranes, and thus the latter only is 
incised. The edges of the incision should then be cauterized, or 
the vesical and vaginal membranes united by a continuous suture, 
to prevent the fistula from closing ; the same end may be furthered 
in a measure by instructing the patient to pass her finger into the 
opening every night and morning. Any troublesome hemorrhage 
at the time of operation may be at once arrested by passing a deep 
transverse ligature through the upper or lower angle of the incis- 
ion, according to the direction from which the blood comes ; any 
such measure will, however, be rarely demanded." 

The actual cautery may be used in making the fistula. After 
the opening is established the vagina should be douched at least 
twice daily with boracic-acid solution, and all parts with which 
the urine may come in contact must be anointed wath cold cream or 
vaseline. 

The bladder may be irrigated as before, allowing the fluid to 
flow through the fistula into a bed-pan. As the fistula must be 
kept patulous until the cystitis is cured, which may require months, 
it will be necessary to have the patient wear some form of ambulatory 
urinal, which can be obtained at any instrument-maker's. After all 
symptoms have disappeared the fistula can be closed in the manner 
described in the article on that subject. 

TuBEECULOsis OF THE Bladder. — Tubcrculosis of the female 
bladder is exceedingly rare, Birch-Hirschfield having found only 4 
cases in 2565 autopsies upon women in the Dresden Hospital. 

The tuberculous process is usually secondary, the primary focus 
being in the lungs or kidney or part of a disseminated miliary tuber- 
culosis. Primary tuberculosis of the bladder is rare — at least the 
diagnosis has not been made frequently, possibly because of difiiculty 
in the past of detecting tubercle bacilli in the urine. Now that 
improved methods of staining bacilli in the urine have been intro- 
duced, this viscus may be more frequently foand to be the primary 
seat of tuberculosis. 

Pathology. — The mucous membrane in the early stage of tuber- 
culosis of the bladder is dotted over indiscriminately with pearly 
nodules about the size of a millet-seed, which are easily distinguish- 
able from the surrounding tissue. Each tubercle conforms to the 
general type of those found in the lungs. These nodules gradually 
enlarge and coalesce, forming grayish- white areas with caseating 
centres. 



DISEASES OF THE UBETHJRA, BLADDER, AND UBETEBS, 639 

Soon these patches break down into ulcers which may be localized 
or involve the entire mucous membrane. Isolated ulcers may pene- 
trate the superficial layers of the bladder and in rare instances 
perforate the wall. 

Diagnosis. — As the symptoms of tuberculosis closely simulate 
those of chronic cystitis, it is often difficult or impossible to differ- 
entiate the two conditions. In all cases of cystitis coming on 
insidiously and without apparent cause tuberculosis may be sus- 
pected, and a careful examination of the lungs should be made to 
discover if they are the seat of primary infection. Having excluded 
the lungs, the kidneys should be carefully examined. It is in these 
cases that the ureteral catheters are of great value. The method 
of catheterization of the ureters, as described in the article on that 
subject, should be followed. The specimens of urine obtained by 
this means should be examined for tubercle bacilli. 

The Demonstration of Tubercle Bacilli in the Urine. — The sedi- 
ment from the suspected urine is obtained from the bottom of a 
conical glass after the urine has stood for some time, or better still, 
by. centrifugalization. Drops of this are spread out in a thin layer 
on several cover-slips, as in the examination of sputum, or, as the 
bacilli are often few in number and it is desirable to examine a 
large surface, somfe of the sediment may be spread out on an ordi- 
nary microscope slide ; after being spread the film is allowed to dry 
in the air, and the cover-glass or glass slide afterward passed quickly 
three times throus^h the flame of a Bun sen burner or an alcohol 
lamp. Care must be taken not to overheat the specimen ; this may 
be avoided, as a rule, by holding the cover-slip between the fingers 
while passing it through the flame. 

The best method of staining for general use is that of Gabbett, 
a modification of the Ziehl-Neelson method. A few drops of the 
following solution — 



Fuchsin, pure, 


1, 


Acid, carbolic, 


5, 


Alcohol, absolute. 


10, 


Aquae destillat., 


100, 



are poured on the cover-glass, which is then held in fine forceps 
over the flame, and heated to boiling for from one-half to one 
minute ; the excess of stain is washed off with water, and the 



640 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

cover-slip immersed for a moment or two in a combined decolor- 
izing fluid and counter-stain (sulphuric acid pure 1, distilled water 3, 
methylene blue to saturation). 

The specimen is immediately washed oiBf in water, and if insuf- 
ficiently decolorized, again immersed in the decolorizing fluid. After 
washing in water, the cover-glass is placed between two folds of good 
filter-paper to remove the excess of water ; the glass is thoroughly 
dried high above the flame, and finally mounted in a drop of xylol 
balsam. 

A good oil-immersion lens (y^ or -^-^) is required for the examina- 
tion. Sometimes the bacilli are numerous, but in many cases there 
are very few, and it may be necessary to look carefully through many 
preparations with the aid of a mechanical stage before finding them. 
It is necessary to warn against the use of old cover-slips, since when 
they have been used for tuberculous specimens before, unless the 
greatest care has been exercised in cleaning them, a few tubercle 
bacilli may have remained which would lead to the making of a 
false diagnosis. 

In the early stage the cystoscope may reveal the miliary nodules 
or the localized caseous area, or later the tuberculous ulcers may 
be seen, and thus the extent of the process determined. As a 
rule, however, the cystoscope is of little value, as the urine is so 
clouded with blood. If tubercle bacilli be found in the urine, and 
other organs are not the seat of primary infection, the diagnosis is 
definite ; but frequently a cystitis which seems to be the result of a 
localized tuberculosis will prove upon catheterization of the ureters 
to be an extension from the kidneys. 

Prognosis. — The prognosis in tuberculous cystitis is always 
unfavorable. The process may be slow in extension, the patient 
dying from the ulceration of the bladder, or from extension to 
other organs, or from general miliary tuberculosis. 

Treatment. — If the infection of the bladder be primary, the 
tuberculous areas should be treated by means of injections or by a 
cystotomy and curettement. If the bladder is opened, it should 
be done in the manner described in the article on Cystitis. The 
tuberculous patches should be thoroughly curetted. It is best to 
allow the vesical fistula to remain open for some time, as free drain- 
age is afforded, and if necessary local remedies may be applied ta 
the diseased area. If the tuberculous cystitis be but secondary or a 



DISEASES OF THE URETHRA, BLADDER, AXD URETERS. 641 

part of a general tuberculosis, irrigation of the bladder may be 
resorted to as a palliative measure. 

A treatment which has been frequently recommended during the 
last year is by injections of iodoformized oil or glycerin. The fol- 
lowing formula has been recommended : 

I^. lodoformi, 50.0 ; 

Glycerini, 40.0 ; 

Mucilag. acaciae, 9.5. 

Sig. Use as an injection thrice daily. 

At first it is best to start with one injection daily. The emulsion 
should be carefully mixed, as there is a tendency for the iodoform 
to collect in small balls in the bladder, which might form the nuclei 
of calculi. 

The general nutrition of the patient should be carefully looked 
into, and the remedies for tuberculosis of the lungs, along with a 
generous diet and a proj)er hygienic regimen, should be prescribed. 

Vesical Calculus. — Vesical calculi rarely occur in women 
because of their patulous and short urethrse. Renal calculi which 
are expelled into the bladder, and in men usually form the nucleus 
for a much larger stone, are in women swept out at the first mictu- 
rition. It is probably very seldom that a stone descends from the 
kidney and remains a sufiicient time in the female bladder to gain 
by accretion a size which prevents its expulsion through the 
urethra. The fact that the largest proportion of calculi in women 
are discovered after the repair of vesical fistulse goes to prove that 
they are formed in the bladder, and are not simply the enlargements 
of stones from the kidney. After vesico-vaginal operations if the 
stitches are allowed to pass through the mucous layer of the blad- 
der, it is probable that the nidus for the stone may be furnished by 
the exposed suture. Emmet claims that such operations are the most 
frequent source of stone in women. Calculi may be of various kinds, 
as uric acid, triple and amorphous phosphates, oxalate of lime, or 
cystine. Phosphatic stones are more frequent in women than in 
men, while those of uric acid are less frequent. It is rather difiicult 
to account for this difference in their occurrence in the two sexes, 
but it is probably due, as explained by a number of writers, to the 
more frequent tendency of men to a gouty or lithemic diathesis. 
Foreign bodies introduced for various purposes by hysterical women 

41 



642 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

may form the nucleus of a stone. Thus, hair-pins, bits of wax, 
buttons, beans, etc. have been found as the centre of vesical calculi. 
Usually the bladder contains but a single calculus, but occasionally 
two or more are found. The most common shape is a flattened 
ovoid, although they may be somewhat rectangular or irregu- 
larly rounded, while phosphatic stones are occasionally curiously 
branched. 

On account of the patulous urethra in women, calculi of small 
dimensions are rarely found ; they vary from the size of a pea to 
that of a walnut and are often much larger. The density of the 
calculus depends upon its chemical composition, the phosphatic 
variety being the most friable and easily crushed. The situation 
of the stone varies with the position of the patient. When she 
is in an upright position, it will usually be found at the base of the 
bladder or blocking the orifice of the urethra, but if recumbent the 
stone will drop back toward the fundus. It may be encysted or 
caught by a fungous mass or retained between the rugse of an 
hypertrophied bladder-wall. If there be a diverticulum in the 
bladder, as is often seen accompanying prolapsus uteri, the stone 
wall be found at the bottom of this sac. Occasionally it is lodged 
in the orifice of an ureter. The author removed a stone within the 
last two years which he had previously located in the mouth of the 
left ureter by means of the ureteral sound. 

Etiology. — The causes of calculi are obscure. The reason for 
the deposit of urinary salts about a foreign body is perfectly patent, 
but the origin of a stone in the centre of which no foreign body can 
be found is not so clear. 

In those cases of prolapsus uteri in which a vesical diverticu- 
lum exists, calculi are prone to form, as these sacs usually contain 
residual urine in which there is a considerable deposit of mucus. 
When one observes, under the microscope, the manner in which 
urinary crystals are often entangled in the shreds of mucus, it 
may quite as reasonably be expected that the same result will take 
place in the diverticulum of the bladder, thus leading to the forma- 
tion of a calculus. 

Symptoms. — The symptoms which are most characteristic of 
stone are frequent micturition, with sudden stoppage in the flow, 
hematuria, and pain. An irregular, halting, and painful flow of 
urine is, of all symptoms, the most characteristic. It usually 
occurs when the stone is small, and is sucked into the vesical mouth 



I 



DISEASES OF THE URETHRA, BLADDER, AND URETERS. 643 

of the urethra, acting as a ball-valve. As it grows in size this 
tendency often entirely disappears. Frequent micturition is usually 
a constant symptom, the patient being compelled to void her urine 
many times during the day, especially when she is on her feet or 
doing active work. During the night this urgent and frequent 
desire to void the urine disappears, and the patient may pass a 
whole night without once getting up. Horseback riding or driving 
over rough roads often causes severe pain. 

The pain in vesical calculus is of two kinds — that directly caused 
by the stone, and that produced by the cystitis which almost inva- 
riably follows as the result of vesical irritation. There is constant, 
heavy, dull pain over the pubes, radiating down into the legs and 
external genitalia and upward to the groin. The pain, which is 
characteristic, is sharp and lancinating, and occurs at the end of 
micturition, frequently being referred to the external genitalia, and 
is so severe at times as to cause the patient to scream. Violent 
straining accompanies micturition, and the attending pain may be 
referred to the rectum or perineum, especially if there are hemor- 
rhoids or if prolapsus of, the rectum exists, ' as frequently results 
from the straining efforts. 

In little girls the pain may be entirely referred to the vulva, and 
lead to a habit of constantly dragging or picking at the parts, which 
causes hypertrophy and excoriation of the labia. 

Hematuria is frequent, but is characteristic only when a few drops 
of bright-red blood appear at the end of micturition. Usually those 
elements only are observed in the urine which occur in cystitis. 

Diagnosis. — Any of the above symptoms may cause the surgeon 
to suspect stone, but a definite diagnosis is impossible until a care- 
ful exploration of the bladder is made. This may be done in one 
of three ways — by the sound (which is the best), by digital explo- 
ration, or by the cystoscope. 

The same precautions should be observed in sounding for stone 
as in catheterization, as prolonged manipulation furnishes the best 
opportunity for the introduction of septic material, if the technique 
is not perfect. The patient should be placed in the lithotomy posi- 
tion, with the thighs flexed upon the abdomen. The vagina and 
external genitalia should be thoroughly washed with soap and water, 
then rinsed with boiled water, and then with bichloride-of-mercury 
solution (1 : 1000), and again with water. 

A piece of gauze one yard square should be spread between the 



644 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

thighs over the buttocks, and a hole made of sufficient size to per- 
mit the free manipulation of the sound. It is also well to have 
the patient's legs enveloped in sterilized stockings or towels. By 
the observance of these small details the best aseptic technique is 
obtained. The bladder should be emptied of its urine, and par- 
tially distended with boracic-acid solution or sterilized water. The 
surgeon either stands or sits between the patient's thighs when 
introducing the sound, which should be previously warmed and 
anointed with sterilized vaseline. In sounding a definite plan 
should be followed : The base of the bladder should be carefully 
explored first, and then the sound should be caused to make excur- 
sions upward and to the sides. During this manipulation two fingers 
of the hand should be introduced into the vagina, and it will be almost 
impossible for a stone to elude the search. 

If this examination be negative and the surgeon is still in doubt, 
he may resort to the cystoscope, or the urethra can be dilated to the 
size of the index finger and a digital exploration made. In this 
way an encysted stone may be detected. In chronic cystitis or 
where vesical neoplasms exist in the wajls of the bladder, or in 
the presence of a tumor encrusted with urinary salts, a peculiar 
grating sound may be elicited by contact with a metallic instru- 
ment. 

The main points of difference as elicited by the sound between 
this condition and stone is the extensive area of deposit and the 
lack of resistance when the instrument is pushed against it. The 
surgeon should always bear in mind that a calculus may be asso- 
ciated with a vesical tumor, a fragment of which has served as the 
nucleus of the stone. 

Prognosis. — If the stone be detected early and removed before 
marked changes in the bladder have occurred, the prognosis is quite 
favorable. On the other hand, if cystitis exist associated with 
hypertrophy and contraction of the wall t)f the bladder, or if there 
is secondary disease of the kidneys, the prognosis is unfavorable, the 
patient often dying from protracted suffering or from the progress 
of the renal disease. This, however, is very rare, as the symptoms 
of stone are usually so urgent as to lead to its detection before such 
grave lesions occur. 

Treatment. — There are three modes of treatment employed in 
cases of vesical calculi in women : by dilatation of the urethra and 
removal of the stone, if small, by forceps, or if large by crushing ; by 



DISEASES OF THE URETHRA, BLADDER, AND URETERS. 645 

kolpo-cystotoray ; and by suprapubic cystotomy. As the urethra 
is capable of considerable dilatation, the first method will, in a cer- 
tain number of cases, be the most available. The urethra should 
not be dilated larger than the girth of a medium-sized forefinger, 
as the sphincter fibres may be lacerated, causing permanent urin- 
ary incontinence. After the urethra has been dilated the surgeon 
introduces his finger into the bladder and locates the stone. If 
not larger than the tip of the little finger, it may be grasped with 
delicate forceps and removed, or coaxed up to the neck of the blad- 
der and out through the urethra by means of two fingers in the 
vagina. Should the stone be large, it is not advisable to remove it 
intact, as the urethra may be so overstretched that incurable incon- 
tinence will result. 

Lithotrity is usually considered the best mode of treatment when 
the stone is not too large or too dense to permit of crushing. The 
patient is placed in the same position for this operation as when 
examined for stone. The urine should be withdrawn, and the 
bladder partially distended with tepid boracic-acid solution. The 
surgeon, sitting between the patient's thighs, introduces the litho- 
trite, previously warmed and anointed wnth sterilized oil or vaseline, 
into the urethra in a line almost perpendicular with the long axis of 
the body. The handle of the instrument is then depressed, when it 
gently glides into the bladder. 

Two fingers of the disengaged hand should then be introduced 
into the vagina and the stone located. An assistant now opens the 
blades of the lithotrite, and with a little manipulation the stone will 
be seized, when the instrument should be very gently rotated to 
obviate the danger of catching the mucous membrane, and the 
screw slowly turned until the stone is crushed ; this will be sud- 
den or gradual according to its composition. The blades are then 
separated and again closed, catching one of the larger fragments, 
and so on until the stone is reduced to small particles. It is rarely 
necessary to resort to an evacuator, as repeated irrigations of the 
bladder are sufiicient to remove the fragments. During the irriga- 
tions the bladder should be gently manipulated between one hand 
introduced into the vagina and the other placed above the pubes. 

Every particle of the stone should be removed, as small frag- 
ments, if left behind, may form the centres of other calculi. If the 
stone be thoroughly pulverized, there is no danger of fragments 
being impacted in the urethra. In case, however, a part of the 



646 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

stone eludes the grasp of the lithotrite and later becomes impacted, 
it may be removed by means of delicate urethral forceps, or, if lodged 
in the mouth of the urethra, it can be pushed back with a sound and 
crushed with the lithotrite. 

Urethral fever is not an infrequent complication following the in- 
troduction of instruments into the bladder, especially after lithotrity. 
It is characterized by the occurrence of rigors, with headache and 
vomiting, followed by febrile reaction. It is especially liable to 
occur in nervous women, but is not a serious complication, and 
usually passes off in one or two days. Temporary aggravation of 
the already existing cystitis may result from manipulation of the 
lithotrite. 

Contra-indications to Lithotrity. — Lithotrity should not be 
resorted to in girls under thirteen years, as the urethra is too small 
to allow sufficient manipulation of the instruments, and as lithotomy 
is such a safe operation at this age, it should always have the pref- 
erence. The size of the stones should be carefully estimated, as 
a stone of a greater diameter than one inch can be more easily 
removed by kolpo-cystotomy. In those cases of sacculated bladder 
occurring in prolapsus uteri or in cystocele, lithotrity is not prac- 
tical, as small particles of the calculus are likely to be left in these 
dependent pouches. Chronic cystitis usually coexists in these cases, 
for which reason cystotomy is preferable, as we thus not only re- 
move the stone, but also secure free drainage, which will often be 
necessary to cure the accompanying inflammation of the bladder. 

If the calculus be associated with a vesical neoplasm, lithotrity 
is contra-indicated, as the manipulation of the lithotrite might induce 
a profuse hemorrhage, and the removal of the stone, if the tumor be 
left behind, would give little or no relief. 

Cystotomy is the next operative measure to be considered if 
removal of the stone through the urethra be contra-indicated. In 
women kolpo-cystotomy is almost invariably the operation of pref- 
erence, as it is comparatively easy and free from danger, and is 
applicable to the largest number of cases. This operation is best 
performed according to Emmet's method, as follows : A shari^ly- 
curved sound is introduced into the bladder so as to depress the 
vesico-vaginal septum. The vaginal side of the septum is then 
caught with a tenaculum and a small opening made, which may be 
enlarged with scissors by cutting upward toward the cervix, keeping 
in the median line and thus avoiding the ureters. If there is only 



DISEASES OF THE URETHRA, BLADDER, AND URETERS. 647 

a mild grade of cystitis, the fistula should be closed immediately 
after extraction of the stone ; on the other hand, should the cysti- 
tis be chronic, with considerable pus and exfoliated epithelium in 
the urine, the opening should be left, thus securing constant 
drainage. 

Suprapubic cystotomy is rarely necessary, but may be required 
in those cases in which the stone is too large to admit of vaginal 
lithotomy. Greater care is necessary in opening the abdomen of 
women than of men not to wound the peritoneum. 

The treatment after all operations for stone is simple. In those 
cases in which the fistula is left open or in which dilatation of the 
urethra is performed, the bed should be well protected with old linen, 
as there will be a constant discharge of urine. 

The parts with which the urine is liable to come in contact should 
be anointed with vaseline, and if there is any tendency to the forma- 
tion of in crusted urinary salts, the parts should be gently scraped 
and anointed with oxide-of-zinc ointment. A light diet must be 
insisted upon, and the urine kept bland by means of an abundant 
ingestion of pure water. Citrate of potash should be administered 
if the urine is acid, and benzoic acid if it is alkaline. The 
patient should return to the surgeon for examination at least once 
every year after the removal of a calculus, to ascertain if there be 
any recurrence. 

Tumors of the Bladder. — The most frequent form of tumor 
occurring primarily in the Madder is the vascular-papillomatous 
fibroma. It usually arises from the superficial layers of the mucous 
membrane, then branches out into slender villous processes, each of 
which is composed of a delicate stroma containing loops of blood- 
vessels. The papillae may be long, or short and velvety. The sur- 
face is covered by stratified epithelium. From its delicate and 
friable character this growth is frequently the seat of hemorrhage, 
as the slighest traumatism may cause bleeding. This tumor ranges 
in size from 2 to 7 cm. in diameter, and may even be larger. 

The most frequent site for papillomatous fibromata is toward the 
base of the bladder at the orifices of the ureters or near the urethra. 
According to Ziegler, this growth should not be described as a *' can- 
cer,'' as it does not belong to the group of malignant tumors. 

Carcinoma of the bladder very rarely occurs as a primary growth, 
but is usually a direct extension of the pathological process from the 
rectum, vagina, or uterus. Primary cancer may, however, arise in any 



648 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

part of the bladder, and take the form of a nodular or fungous 
tumor. It grows rapidly, and soon becomes necrotic, breaking 
down into ragged, ulcerated areas which may perforate the blad- 
der-walls. 

Other neoplasms are exceedingly rare, yet any one of the follow- 
ing may occur : myoma, fibro-myoma, myxoma, sarcoma, fibro- 
sarcoma, adenoma, and, very rarely, dermoid cyst. Polyps also 
occasionally arise from the vesical mucous membrane. Hypertrophy 
of the bladder-walls, which may assume a polypoid form, usually 
occurs as a result of chronic cystitis, and will be spoken of under 
that heading. 

Symptoms. — In the early stage of any neoplasm the symptoms 
are not pathognomonic, usually simulating those of cystitis or vesical 
calculus. The first symjDtom usually noticed is painful micturition, 
caused by the irritation or mild cystitis which is set up by the grow- 
ing tumor. In the papillary growth, however, a sudden hematuria 
may be the first symptom. 

If the new growth be near the internal urethral orifice or is 
pedunculated, urination may be difficult and halting, as in vesical 
calculus, or if the tumor becomes lodged in the urethra, there may 
be retention. As the growth increases in size, the pain experienced 
during micturition grows more intense, and continues for an hour or 
more afterward. There is heavy, dull pain over the bladder, which 
radiates into the legs, upward toward the inguinal and lower lum- 
bar regions. 

By this time hematuria occurs if it has not occurred before. 
The urine is at first only slightly tinged with blood or may be of a 
bright-red color, due to a sudden and profuse hemorrhage. Days 
may pass, and the urine be comparatively normal before blood is 
again noticed. The sudden hemorrhages occurring in the papil- 
lary growths often seem to be entirely free from traumatic causes, 
the patient, perhaps, awakening in the night with a desire to void 
her urine, and finding that it is almost pure blood. The cystitis, 
which is at first mild, becomes more intense as the tumor increases 
in size, and the urine, which has been acid, gradually becomes neu- 
tral, and later intensely alkaline. 

There is in many cases a constant desire to micturate, resulting in 
small quantities of bloody urine being voided. As the alkalinity of 
the urine increases, the urinary salts are precipitated, and may form 
incrustations on the tumor. On examining a freshly- voided speci- 



DISEASES OF THE URETHRA, BLADDER, AND URETERS, 649 

men of urine, it will usually be found to have a light or dark red- 
dish opacity. After standing for a few hours, the supernatant 
urine frequently does not clear up. This may be due to micrococci, 
or schizomycetes, which are found in myriads. There are usually 
two strata of precipitate — an upper red or tenacious, and a lower or 
yellowish. If the alkalinity be quite decided, the urine will be 
loaded with a thick, tenacious mucus. On microscopic examination 
there are observed a large number of red and white corpuscles, and 
if the specimen has been lately voided, these cells will be only 
slightly changed in form. The appearance of the urine in these 
cases differs from that of cystitis only in the larger number of red 
corpuscles and the fragments of the neoplasm if present. The odor 
of the urine is usually ammoniacal and excessively fetid. If the 
tumor be malignant, the symptoms are more rapid in their onset, 
and the termination much more quickly fatal. 

In papillary growths and other benign tumors the hemorrhage 
from the bladder may be so excessive as to cause a grave secondary 
anemia resembling closely the cachexia of malignant tumors. 

If nothing be done to arrest the growth of these tumors, the 
patient becomes emaciated, defecation may be excessively painful, 
the pain in the vesical area and in the lower lumbar region is 
intense, and she has the general appearance of one suffering the 
severest pain. In no disease is there more pain than in some of 
these cases, while others may be comparatively free from discomfort 
for many years. 

Diagnosis. — In rare cases, in which hematuria is the only symp- 
tom at the onset of the growth, a diagnosis is impossible, on account 
of the many conditions which may give rise to blood in the urine, as 
the filaria sanguinis hominis, the plasmodium malarise, and various 
diseases of the blood. As this symptom is rarely unaccompanied 
by others which point more or less directly to the disease, it is best 
to consider it in conjunction with them. 

In cystitis the red corpuscles are much fewer and less frequently 
shed, and the fragments of tumor, of course, never observed. The 
onset in cystitis is more acute, and usually disappears if judicious 
treatment be instituted. The symptoms of vesical calculus may be 
exceedingly difficult to differentiate, as a tumor situated near the 
beginning of the urethra may give rise to symptoms so closely 
simulating those of stone as to render a diagnosis impossible with- 
out the use of the sound or cystoscopy In rare cases the two con- 



650 AN AMEBICAN TEXT-BOOK OF GYNECOLOGY, 

ditions may be associated, and the presence of the stone detected, 
while the tumor is entirely overlooked. 

If a sound be introduced, it should be manipulated with the 
greatest gentleness, a violent hemorrhage often arising if the tumor 
be harshly touched. The ease with which the hemorrhage starts is 
a strong point in favor of tumor. If the growth be large, its out- 
lines may be made out, but this is rarely reliable, as the hypertro- 
phied mucous membrane arranged in folds may be easily mistaken 
for a tumor. 

Small fragments of the growth may be dislodged, which at once 
renders the diagnosis clear. If the presence of stone be excluded 
and the diagnosis be still in doubt, it is well to dilate the urethra 
with Hegar's dilators, introduce the fingers, make a careful dig- 
ital exploration, and thus arrive at definite conclusions. 

Should a tumor be present, it is always desirable to know its 
nature, whether benign or malignant, sessile or pedunculated, local- 
ized or diffuse. A small piece should be removed for microscopical 
examination by snipping it off with scissors, or by curettement with 
the finger-nail or an ordinary uterine curette. In skilled hands 
the cystoscope may render a diagnosis easy, and it is in these cases 
that this instrument has done its most brilliant work. 

Prognosis. — Carcinoma of the bladder is invariably fatal, and 
terminates the patient's life in from six to eighteen months. Benign 
tumors, if removed early, are usually followed by recovery. If, 
however, they are allowed to remain until a grave cystitis has been 
induced and the patient has become pale and emaciated, the prog- 
nosis is not so hopeful, as at best the recovery will be slow. Pyone- 
phrosis, purulent ureteritis, or hydronephrosis may have resulted 
from pressure or occlusion of the ureters, in which case death is 
the most likely termination. If the benign tumor be thoroughly 
removed, there will be no return. In many cases the growth recurs 
on account of the failure in complete extirpation, due to insuperable 
difiiculties from the impossibility of gaining complete access to all 
parts of the bladder. 

Treatment. — There are three avenues of approach for the 
removal of tumors of the bladder — through the urethra, through 
a vaginal incision, or through a suprapubic incision. The first is 
always to be preferred if the tumor is not too large. 

The urethra should first be well dilated with Hegar's dilators, 
running up as high, in carefully watched cases, as No. 23. The 



DISEASES OF THE URETHRA, BLADDER, AND URETERS. 651 

index finger may now be introduced and the bladder carefully 
explored. If the tumor be pedunculated, it can be grasped with 
artery forceps and removed by torsion. In case it be larger and 
have a broad base or pedicle, the ecraseur may be employed to 
crush it off. In some cases the tumor may be caught with toothed 
forceps and brought down to the urethral orifice, where its pedicle 
can be transfixed and tied off and the mass removed with scissors or 
knife. If the tumor be sessile and spread out over the mucous 
surface as a velvety growth, it is well to resort to the curette or, 
as has been done in some cases, the finger-nail. Hemorrhage is 
rarely free or persistent, as the removal of the villous growth with 
its abundance of delicate blood-vessels takes away the source of hem- 
orrhage. If, however, the bleeding persist, the bladder may be 
irrigated with warm water, and if this does not control it, the blad- 
der can be illuminated and the bleeding point touched with some 
styptic, as Monsel's solution. Styptics are to be avoided if possible, 
as they cause superficial necrosis and firm black clots, which keep 
up a disagreeable discharge for many days. The introduction of 
small pieces of ice, or a saturated solution of boracic acid, or pack- 
ing the vagina tightly with gauze, with counter-pressure above the 
pubes, may be resorted to should other means fail to control the 
hemorrhage. 

If the tumor be too large for removal through the urethra, vagi- 
nal cystotomy (kolpo-cystotomy) should be performed. The incision 
should not encroach on the sphincter vesicae, although its division 
need not result in incontinence of urine if it be promptly united. 
In the majority of cases the tumor is easily removed, as the operator 
gains ready access to its site through the vaginal opening. 

If the tumor be malignant, it can be curetted and lightly cauter- 
ized, which will greatly alleviate the patient's suffering. 

If urination is painful and a high grade of cystitis is present, it 
is best not to close the vaginal incision, as free drainage of the blad- 
der adds greatly to the patient's comfort. It is rarely necessary to 
resort to suprapubic cystotomy in the female for removal of tumors. 
Baker, of Boston, makes the statement that suprapubic cystotomy 
has never been done in the female for vesical neoplasm. 

After removal of the growth a daily douche of boracic acid (8 
to 12 gr. to the ounce), at a temperature of 110° F., may be given. 
In this way the bladder is cleared of residual urine and the debris 
thrown off from the granulating surfaces. The urine should be 



652 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

kept bland and unirritating by a liberal ingestion of lithia or other 
pure water, and in addition potassium citrate or boracic and benzoic 
acids may be administered. Following dilatation of the urethra there 
will be urinary incontinence for days, and even weeks, until the cir- 
cular muscles regain their normal tonus. If the patient suffer ex- 
cessively, belladonna, iodoform, or opium suppositories may be 
employed. 

If the vaginal incision be closed immediately after the tumor is 
removed, it will be necessary to catheterize every two hours for the 
first twenty-four, and every three or four hours thereafter. A self- 
retaining catheter is not necessary. 

Inversion of the Bladder. — This is a rare affection, and but 
few^ cases are reported. 

The protruding vesical wall is readily reduced if not strangu- 
lated, but is apt to re-descend if some measure is not instituted to 
retain it in position. In one case reported the protrusion of the 
invaginated bladder appeared so much like a red vascular tumor as 
to cause the surgeon to make all prejDaration for its excision. At 
the last moment the orifice of a ureter was discovered, and led to 
the proper diagnosis. 

This condition, like prolapsus of the urethra and rectum, is 
found most frequently in children. It is usually of gradual forma- 
tion, descending slowly and equably dilating the urethra. When 
the bladder first appears at the external orifice of the urethra, it 
resembles the prolapsed urethral mucous membrane; later, how- 
ever, it becomes larger and larger, until the entire organ may 
protrude. Violent expulsive efforts of any kind are the exciting 
causes. 

Symptoms. — Partial prolapse into the urethra before the bladder 
appears at the external meatus is said to be attended by symptoms 
similar to those of vesical calculus. A more extensive prolapsus 
usually gives rise to expulsive efforts and abdominal pain in the 
adult, but in children it is usually painless, and the presence of the 
tumor first calls attention to the condition. The tumor is of vary- 
ing size, from that of a marble to that of an orange. 

Diagnosis. — The diagnostic point between prolapsus of the 
urethra and bladder is the continuation of the prolapsed mucous 
membrane in the former with the vestibular mucous membrane. In 
prolapsus of the bladder a fine probe can be passed into the urethra 
alongside of the protruding membrane, while the same maneuver is 



DISEASES OF THE URETHRA, BLADDER, AND URETERS. 653 

not possible if only the urethra has descended. If the prolapsus is 
marked, the ureteral orifices may appear external to the meatus, 
when the urine will be seen flowing from their orifices in little jets. 
In vesical or urethral polyp the pedicle would serve to differentiate 
these two conditions, but if this is not sufficient for diao-nosis, the 
polyp can be returned into the urethra ; if reducible, it can still be 
felt by digital examination, while such would not be the case on 
reduction of the prolapsed bladder. 

Treatment. — The patient should be placed in the lithotomy 
position, and the bladder returned in the same manner as a hernia 
is reduced. This is usually effected with great ease, but the prolapse 
may return of its own accord when the patient assumes the recum- 
bent position. 

The patient should rest in bed for at least one week. Often there 
is slight or no relaxation of the urethra ; in such cases little is indi- 
cated further than postural treatment. If there is great relaxation 
of the urethra, with incontinence of urine, it may be necessary to 
narrow its caliber by an operation through the urethro-vaginal 
septum. This may be accomplished by means of the linear excision 
of a portion of the urethral wall, followed by closure with sutures 
of fine silk or silkworm-gut. Some writers recommend linear 
cauterization within the urethra, thus narrowing the caliber by the 
subsequent formation of cicatricial tissue. 

In all cases there is a liability to permanent incontinence. 

Diseases of the Ueeters. 

The ureters are liable to ascending disease from the bladder or to 
secondary involvement or descending disease from the kidney ; to 
intrinsic disease, which begins primarily in the ureter itself, or, 
again, to involvement between its renal and vesical terminations by 
continuity from the disease of some neighboring organ. 

One or both ureters may be affected, and, according as one or 
both are involved and to the gravity of the affection, the prognosis 
varies. A serious affection of both ureters is incompatible with 
long life, as secondary changes sooner or later occur in the respect- 
ive kidney or kidneys interfering with the excretion of urea. 

Diseases of the ureters have only recently begun to attract that 
attention which their importance demands, and although the thera- 
peutic means at our command are far behind our diagnostic precision 
in the female, the former are making rapid strides. 



654 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



The DIAGNOSIS of disease of the ureters is made by recognizing 
alterations in the caliber of the ureter ; thus in inflammatory disease, 
whether intrinsic, arising from extension of inflammatory disease 
upward from the bladder, or downward from the kidney, the ureter 
of the affected side becomes enlarged (ureteritis) and in more vio- 

FiG. 354. 



VptN 







Pelvic Portion of the Ureter viewed from below. 



lent forms of inflammation the surrounding connective tissue is also 
involved (peri-ureteritis) . The normal ureter can be palpated in 
four cases out of five through the antero-lateral wall of the vagina 
in its upper third, where it is felt to roll under the finger like 
a small soft cord. By pressing down through the superior 
strait with the disengaged hand the examination is often greatly 
facilitated. 

An enlarged ureter gives the sensation to the finger of a rigid 
cord, or even of a lead-pencil. It is always very sensitive upon pres- 



DISEASES OF THE URETHRA, BLADDER, AND URETERS 655 

sure, which usually produces a strong desire to urinate; this is 
especially characteristic of affections in the lower part of the ureter. 
Behind the broad ligament an enlarged ureter may be mistaken for 
an adherent and sensitive ovary. Back of this point the normal 
ureter cannot be traced, unless a catheter is first inserted through 
the bladder and carried up to the pelvic brim. The ureter may 



Fig. 355. 



OSTVjRNrr; 




Pelvic Portion of the Ureter viewed from above. 



then be readily felt upon the catheter by a finger iht>jduced into 
the rectum. An enlarged ureter can readily be felt per rectum from 
the broad ligament up to the pelvic brim. The course of the ureter 
in the upper part of the pelvis usually lies to the inside of the 
internal iliac artery, which can be palpated. It occasionally lies 
on the other side of the vessel. The only point at which the 
ureter can be palpated distinctly in the abdomen is over the brim 
of the superior strait. The landmark for the point at which it 



656 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



crosses the brim is located by first making deep pressure upon 
the promontory of the sacrum. A little below this point, and 
from 2.5 cm. to 3 cm. on either side, the common iliac artery 
will be felt, at which point the ureter crosses it to drop into the 



Fig. 356. 




Course of the Ureters marked on the Abdomen. 



pelvic cavity. Above this point an inflamed ureter may some- 
times be located by a line of tenderness on pressure. 

Sounding and Catheterizing the Ureters. — A sound or a catheter 
can be introduced into one or both ureters in the following manner : 
The patient is brought with her buttocks to the edge of the table, 
the legs and thighs being sharply flexed. The vulva and vagina are 
cleansed with soap and water. The urine in the bladder is drawn 
off and put to one side. The bladder is then injected with 150-200 
cc. of a methyl-blue solution. The posterior wall of the vagina is 
now retracted with a Sims or a Simon speculum which exposes the 
anterior wall. On close inspection two prominent folds will be seen 







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DISEASES OF THE URETHRA, BLADDER, AND URETERS. 657 

sweeping over the anterior wall about halfway up, and out to the sides 
on to the lateral walls toward the cervix. These are the ureteral folds, 
so called by Pawlik, the pioneer in this work. Parallel to, and just 
above these folds the ureters are to be sought. One of Kelly's 
ureteral sounds is now taken in hand, introduced through the ure- 
thra into the bladder, and held with the concavity of its extrem- 

FiG. 357. 




Kelly's Ureteral Sounds. 

ity toward the floor of the bladder. A little pressure on the floor 
reveals its position to the eye. The sound is now guided with a 
sweeping motion out in the direction of the ureteral folds. If it 
catches in the ureter, the sound will at once be felt to have a deter- 
minate direction, and it slips on backward and outward toward the 
posterior pelvic wall. The ureter may now be palpated on the 

Fig. 358. 




Kelly's Ureteral Catheters. 

sound. If the catheter is in the ureter, after waiting a few minutes 
the urine begins to flow, drop by drop, clear and unmixed with the 
methyl solution, demonstrating that it is being collected at a point 
above the bladder. 

A ureteral stricture will be recognized with the bougie, sound, or 
catheter by its " bite." Below the stricture no discharge of urine 

42 



658 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 



will take place, but when passed above it a large quantity of urine 
flows through the catheter in a steady stream within a short time 
(say from 40-60 cc. in from two to three minutes), thus demon- 
strating the presence of a hydro-ureter. 

The treatment of such a condition is dilatation by graduated 
bougies. Stricture, however, is rarely an uncomplicated affection. 

Stone in the lower part of the ureter may be felt by the sound 
above a stricture, or even as low down as the vesical termination of 



Fig. 359. 




Catheterization of both Ureters. Left-hand glass showing greatest quantity of urine secreted during a 
given interval ; urine clear. Right-hand glass showing much smaller quantity of urine secreted ; 
urine bloody, indicating the diseased kidney and the character of the disease. 

the ureter. In the latter situation the stone may be recognized by 
an endoscope. A stone as low down as this may be extracted by a 
pair of forceps introduced through the urethra. A stone located 
higher up may be enucleated, after locating it by means of the sound 
and by touch, through an incision in the antero-lateral wall or in the 
vault of the vagina. The incision should be closed at once with 
silkworm-gut and fine silk sutures. 

Cancer of the ureter almost invariably extends from the bladder, 
occluding its lumen and producing uremia. 

Cancer of the uterus extending out into the broad ligaments com- 
monly involves the ureters by 2)ressure, producing hydro-ureter, 
hydronephrosis, nephritis, and finally death from uremic poisoning. 



DISEASES OF THE URETHRA, BLADDER, AND URETERS, 659 

Ureteritis or an interstitial thickening of the fibrous coat of the 
ureter is sometimes found without apparent cause. The ureter 
feels like a distinct thickened cord, tender to pressure. Its lumen 
is encroached upon and the symptoms of stricture soon supervene. 
Attempts should be made to dilate the ureter with sounds. If 
one side is affected in its advanced stages, the kidney may call for 
removal. If both sides are affected, an opening may be made in 
each loin, draining the pelvis of the kidneys, and thus prolong- 
ing life. 



AFTER-TREATMENT IN GYNECOLOGICAL OPERATIONS. 



Abdominal Section. 



The importance of this whole subject is realized by every sur- 
geon engaged in the practice of gynecological operations, and the 
want of some convenient literature to which reference may be made 
has often been deplored. 

There are certain well-defined principles which may be followed 
in conducting the after-treatment of a patient upon whom an abdom- 
inal section has been performed, but concerning the details of any 
given case, the surgeon must be governed in great measure by the 
conditions as they arise. These conditions may best be met and 
overcome by carrying out the principles to be enunciated, and by 
deviating from them only when an emergency arises ; even then 
keeping well in view the general objects to be obtained. 

Rest. — When the patient leaves the operating table rest is to be 
the first consideration — rest for the body, rest for the mind ; the lat- 
ter can only be attained simultaneously with the first. The woman 
should be placed upon her back, and kept in that position for the 
first few days or until her bowels have been moved. If a drainage- 
tube, especially a glass one, has been employed, she must remain in 
this position until it is removed. While upon her back the knees 
may be drawn Up or the legs extended, as is most comfortable for 
her. She will frequently desire a change of their position, which 
should always be made by the nurse. While the knees are drawn 
up they are to be supported by a pillow inserted under them, so as 
to remove the strain incident upon the muscular effort necessary 
to keep them in position if left to themselves. It is never to be 
forgotten that when a patient lies for a considerable length of 
time in any one position every crease or wrinkle in the bed-linen 
becomes a source of annoyance, if not of great discomfort. The 
woman is intensely uncomfortable, and is suffering considerably 
from pain at the best, and every possible added source of discora- 

660 



AFTEB-TBEATMENT IN GYNECOLOGICAL OPEBATIONS. 661 

fort must be removed. She is sure to suffer a great deal of pain 
and discomfort as the result of her operation, and if kept on her 
back she naturally attributes all the discomfort to the position, 
when in reality it is not so. It should be one of the chief objects 
of the nurse from the first to keep both the bed-gown and the sheets 
under the patient's back perfectly smooth. A woman will beg hard 
to be allowed to turn, if only for a moment, when, if her clotMlng and 
the bed-sheets are smoothed out and her pillows shaken up, she will 
be rendered fairly comfortable, and will remain so for a consider- 
able length of time. This absolute rest upon the back is desirable 
for a number of reasons : If she is allowed a little liberty, she will 
toss and turn about, hoping to find relief first in one position, then 
in another, only to fail ; but in the meanwhile a ligature which has 
been loosely placed or which encircles an especially large pedicle 
is unable to withstand the tension it is placed under, and bleeding 
begins — possibly only slight in amount, but it may be sufiicient to 
kill. When a drainage-tube is used, if made of glass, it is very 
likely to become broken, and if of any other material, displaced. 
The stomach, which is already irritable, becomes worse, and the 
vomiting is not so quickly controlled. Every movement causes 
the patient pain, and if the edges of the abdominal wound are not 
closely coapted, they are apt to become displaced, as are also the 
dressings. The pulse is always more steady with the patient in the 
dorsal position. 

Vomiting. — Rest must not only be obtained for the body but 
also for the stomach. The anesthetic has rendered that organ 
so irritable that the slightest disturbance causes it to reject 
anything it may contain. The retching and vomiting follow- 
ing abdominal section are exaggerated over and above that from 
simple anesthesia. The symptom is to be treated by rest, pure and 
simple. Under any circumstances the organ will remain irritable 
until the effect of the anesthetic has worn away, and drugs will not 
improve its condition materially : it will be extremely fortunate if 
they do not render it worse. The treatment of the vomiting con- 
sists in allowing the stomach to remain quiet. This is best accom- 
plished by withholding drugs, stimulants, food, or water. Abso- 
lutely nothing should be allowed to pass the patient's lips until the 
vomiting has ceased, which will generally be within from twelve to 
twenty hours. Should it be necessary to administer nourishment ' 
during this time, rectal enemata may be used ; however, the patient 



662 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

usually does very well without either nourishment or stimulants 
for several days. 

Drink. — It is well to withhold fluids until the vomiting has 
entirely ceased, and then to administer them only in small quantities. 
They should be begun by allowing a small spoonful of hydrant- or 
soda-water every fifteen minutes, testing the ability of the stomach to 
retain fnd absorb it, and gradually increasing the quantity until 
within twelve hours the patient is taking an ounce each hour. The 
mouth may be moistened and cleansed during the interval of vom- 
iting immediately succeeding the operation, by the aid of a wet cloth 
on the finger of the nurse. Should the thirst become intolerable 
during this period, it may be relieved by administering an enema 
of two or three ounces of hot water at intervals of four hours. 
The habit of giving ice by the mouth is bad and should be 
avoided. The cold water accumulates in the already over-irritated 
stomach, which is in no condition to absorb, until it finally 
is rejected, in the meanwhile having rendered the patient more 
uncomfortable. The intense thirst created by the withholding of 
drink is a great desideratum, as the blood-vessels, being unable to 
satisfy their demand for fluids from the stomach, draw upon the 
serum and blood which have accumulated in the pelvis. An 
amount of septic matter of which the peritoneum might readily 
dispose may cause a septic peritonitis and death if it can find so 
favorable a medium in which to develop as is aflbrded by this 
accumulated bloody serum. 

Food. — For the same reason that it is unwise to give drink it is 
best to withhold food. The stomach will not retain it until it has 
recovered from the irritation of the ether : even should food be 
retained, it will accumulate and remain unabsorbed, the added 
irritation of its presence causing an excessive pouring-out of gastric 
juice and considerable discomfort to the patient. In addition, 
purgatives will not act so readily when administered together with 
food, and it is desirable to have the bowels move as soon after an 
operation as possible. If food lay on the stomach for any length 
of time, decomposition sets in and flatulence is induced. Food may 
be safely withheld for forty-eight hours excepting in unusual cases, 
when, if it be required, it may be given in the form of enemata ; 
stimulants may be administered in the same manner when indicated. 
When the stomach has shown itself thoroughly tolerant to drink, 
it is then time to begin to ofier the patient fluid nourishment. 



AFTER-TREATMENT IN GYNECOLOGICAL OPERATIONS. 663 

Buttermilk is most acceptable to the majority of women. It 
should be given in small quantities often repeated, half an ounce 
every hour or two, testing the capability of the stomach to retain 
and digest it. It is not wise to attempt too much in the way of 
feeding until the purgatives have gotten well under way. Milk, 
unless predigested, is not a good food for this class of patients ; it 
almost invariably causes the formation of flatus. Beef-tea or beef- 
extracts may be alternated with the buttermilk. Soups or broths 
of any kind may be substituted as the patient tires of one or the 
other. In fact, any article of soft diet which is suitable for the 
sick-room may be of service, the greater the variety the better. 
As soon as the bowels have been opened, usually in about forty- 
eight hours, the patient's appetite begins to assert itself, and where 
before she took what was offered her under protest, she will now 
begin to enjoy what she is given. It is at this time perfectly safe 
to consult her appetite; anything that she fancies may be given 
her. As a matter of fact, for the first four days after the operation 
she will want little but soft or semi-soft food, but if after the bowels 
are opened she wishes solid food, it can do no harm to allow her 
to have it. She has been starved for three or four days ; now feed 
her generously. There are exceptions to this, but they will be 
noted in their proper places. 

Purgatives, — It is imperative to obtain a movement of the bowels 
at as early a date after operation as possible. The condition of the 
bowels and pulse is the surest indication of the progress of the 
patient. If at the end of forty-eight or sixty hours a good and 
satisfactory movement of the bowels has been obtained, and the 
pulse be below 100 beats to the minute, the patient is convalescent. 
If, on the other hand, the bowels remain unmoved in S23ite of all 
efforts to open them, tympany begins to appear, and the pulse 
slowly rises to the neighborhood of 120 beats to the minute or 
higher, it is a serious matter for the patient. The one hope under 
these circumstances is to get the intestinal canal open, and it is at 
times astounding to note the great change for the better which takes 
place when this has been satisfactorily accomplished. The distress 
incident to the distension will have disappeared, the vomiting will 
have ceased, the pulse will have dropped to the neighborhood of nor- 
mal, the anxious expression of the face will have cleared away, and 
the patient will look and express herself as feeling very much better 
in all respects. The alteration is that of complete change from an 



664 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

appearance and condition of extreme distress and suffering to one 
of absolute contentment and comfort. Twelve or fourteen hours 
after the operation, or as soon as the vomiting has ceased, calomel 
in grain doses, to be repeated each hour, should be given until eight 
or ten doses have been taken : this should be followed by a Seid- 
litz powder or a teaspoonful of Rochelle or Epsom salts every two 
hours until the desired effect is accomplished. As soon as flatus is 
passed or the saline is rejected, a large enema of hot soapsuds, a 
quart or more, containing a tablespoonful of turpentine, should be 
given : the enema may be repeated at intervals of two or three 
hours if necessary. Calomel will be retained upon the stomach 
when everything else is rejected, but there must be a limit to the 
administration of this drug, else the patient will become salivated. 
A stomach which is ejecting everything will become settled when 
the calomel is begun. If the magnesia salts are not retained, some 
other form of drug will have to be used, such as compound licorice 
powder, or, in desperate cases, even croton oil. When the bowels 
have not responded to treatment by the end of the third day after 
operation and the pulse has gradually risen to 130 beats or more, it 
is the exceptional case which recovers : such patients are generally 
dead by the end of the fourth day. Efforts to obtain the desired 
result should not cease until the case is clearly hopeless. If the 
bowels do respond, even apparently desperate cases at times rally 
quickly, and are convalescent in a few hours. The depletion of 
the blood-vessels incident to the purgation is another factor in caus- 
ing the absorption of the bloody serum in the peritoneal cavity, and 
for this reason, if for no other, it is desirable to secure a number of 
watery stools. A daily movement should be secured subsequently. 
Should any of the intestines become injured during the course 
of the operation, and there is danger of fecal extravasation, absolute 
rest must be obtained for the bowels until such time as Nature may 
protect the dangerous point with peritoneal lymph and adhesions. 
Under these circumstances morphia may be administered hypoder- 
matically in quarter- grain doses repeated sufficiently often to keep 
the intestines quiet. Three or four doses in the twenty-four hours 
will answer the purpose : possibly opium suppositories of one grain 
each, repeated at intervals of six or eight hours, would answer 
just as well or better. The opiate, in addition to helping to 
inhibit the peristaltic action of the intestines and tending to prevent 
the natural secretions in the gut, allays the irritability of the stomach 



AFTEB-TBEATMENT IN GYNECOLOGICAL OPERATIONS. 665 

and prevents retching or vomiting until such time as the adhesions 
and lymph have become strong enough to offer the necessary resist- 
ance. Should vomiting occur during the first few days, almost cer- 
tainly will the intestinal contents be forced through the light barrier 
formed by the lymph and into the pelvic and abdominal cavity. 
No effort should be made to move the bowels for at least four days 
after operation, when small doses of magnesium sulphate or castor oil 
may be administered, followed by an enema of soap and hot water 
as soon as the patient feels a tendency for the bowels to move. 
Great care should always be observed in such cases in giving the 
enema that the bowels be not over-distended, else irreparable 
damage may result. If the injury has been to the small intestine, 
it will have been repaired with stitches at the time of the operation, 
and little difference need be observed in the after-treatment except 
that purgatives should not be begun until the end of the second or 
third day. Not much harm can occur from an injury so high up. 
Where the damage is to the sigmoid flexure of the colon or to 
the rectum, as is most generally the case, it is so low down in the 
.pelvis that the sutures cannot be satisfactorily or safely placed, and 
unless great care is observed, irretrievable damage may be done 
when the bowels are allowed to open. It is not a good plan to 
allow the intestine to remain quiescent for too long a time, else the 
colon and rectum will become filled with scybalous masses which 
may prevent closure of a laceration or may tear it open after it is 
partially healed. When the bowels have once moved they should 
be opened daily, if not acting naturally, by a laxative or an enema. 
Bladder. — Should it become necessary, the urine may be with- 
drawn with the aid of a catheter. It is only, however, when abso- 
lutely necessary that the catheter should be used. If a proper 
length of time is allowed to lapse after the operation, most 
patients will void their own urine, and, having once done so, there 
will be no further necessity for the use of the instrument. If the 
bladder is once relieved artificially, it is most likely that it will 
be again demanded by the patient, and if the temptation be yielded 
to a few times, it will be difiicult to break up the habit. It is best, 
if possible, to force the patient to pass her own urine from the 
start, and if she is watched carefully for any untoward symptoms, 
the urine may be allowed to accumulate for from fifteen to twenty 
hours if necessary, the patient being offered the bed-pan occasionally 
during this interval, and every effort being made to aid her in her 



666 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

endeavors to accomplish the act of urination. A small stream of 
warm water squeezed from a sponge, if allowed to run down over 
the meatus at times, accomplishes the result. When the catheter is 
used, the greatest care should be taken that the bladder is not in- 
fected. The instrument should be preferably a soft-rubber one, 
and should be antiseptically clean. It should have been prepared 
by being immersed in boiling water, washed in a bichloride-of- 
mercury or carbolic-acid solution, and kept until needed in alcohol. 
It should never be used without fully exposing the parts. The 
patient's knees being well drawn up and separated, the labia are 
drawn apart with the finger of one hand and the meatus exposed 
to view. The parts are thoroughly cleansed with a piece of cotton 
wet with a carbolic-acid or bichloride-of-mercury solution, and the 
point of the catheter introduced directly into the meatus without 
being allowed to come in contact with any of the parts. Thus, 
and only thus, can the patient's bladder be ensured against infec- 
tion. A cystitis at this stage of the convalescence will often give 
rise to serious symptoms and an immense deal of discomfort, to 
say nothing of danger to the patient. 

If during the operation the bladder has been injured or torn 
open, whether it has been sutured or not, the after-management of 
the urine must differ somewhat from that which is usual. If under 
these circumstances the organ is allowed to become distended, 
there is apt to be leakage at the point of injury between the 
sutures, or if only the outer coats of its walls have been torn away 
in separating adhesions, a rupture might readily occur at this 
point were the urine not removed for fifteen or twenty hours. It 
should always be arranged in case of such injuries that there be no 
accumulation allowed. A soft-rubber catheter may be left in the 
bladder permanently, by means of which the contents can be con- 
veyed into a vessel over the side of the bed, through a long piece 
of drainage tubing attached to the end of the catheter ; or, better 
still, a self-retaining female catheter may be utilized for this pur- 
pose. Three or four days will be sufiicient for its use, after which 
the patient may be catheterized five or six times in the twenty-four 
hours, the use of the instrument becoming gradually less frequent, 
until in a week or ten days it may be omitted altogether. If dur- 
ing the convalescence cystitis should develop, it becomes necessary 
to treat it promptly. A careful inspection of the methods of cathe- 
terization should be made, and rectified if found faultv. The vast 



AFTEB-TBEATMENT IN GYNECOLOGICAL OPEBATIONS, 667 

majority of cases arise from this source. Diuretics should be ad- 
ministered freely, provided the stomach has reached the state 
when it can bear them. 

If the cystitis develops within the first day or two, before 
the bowels are thoroughly opened, all internal medication is 
better withheld for the time and local treatment depended upon. 
In any event, most reliance must be placed upon the local 
management, irrigating the bladder twice daily with a mild 
antiseptic solution, and seeing that no residual urine remains to 
undergo decomposition. A warm solution of permanganate of 
potash, not sufficiently strong to cause burning, may be passed 
into the bladder until the patient complain of the distress. This is 
accomplished by the aid of a soft-rubber catheter with a piece of long 
rubber tubing attached, terminating at the opposite end in a small 
funnel. The funnel is elevated, and the fluid allowed to enter the 
bladder through the introduced catheter, by the force of gravity. 
As soon as the woman complains of much pain, the funnel may be 
depressed into a vessel resting on the floor, and the solution allowed 
to siphon away. The action of the residual urine will have decom- 
posed the permanganate of potash in the solution, and it will return 
almost the color of ordinary water. It is then necessary to refill 
the bladder with a fresh solution, in order that the unaltered drug 
may come in contact with the inflamed and suppurating walls. After 
a few washings the patient will become more comfortable and the 
cure will be accomplished quickly. The urine in the mean while 
must be rendered as nearly neutral as possible. 

If there is preexisting kidney disease, symptoms of uremia may 
develop after the operation. The quantity of urine voided should 
be carefully noted and this symptom anticipated : following the ope- 
ration, the quantity of urine secreted during the first few days is 
always small, and due allowance must be made for this. The treat- 
ment of this complication will be similar to that of uremia under 
any other circumstances. If it once develops, the patient is usually 
lost, although an occasional case is saved by prompt action. Purga- 
tion, diuretics, heat, and local bleeding are all indicated, and must 
be applied promptly if any good is to be derived from them. Cro- 
ton oil for purgation, cocaine for diuresis, leeches and cupping over 
the kidneys for bleeding, and dry heat applied about the parts, are 
the chief remedies to meet the indications. 

Bathing. — Bathing is an important element in the comfort of an 



668 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

operative case, and should be begun as soon after operation as pos- 
sible. The bowels will, in a normal case, be opened by the end of 
forty-eight or sixty hours. As soon after this as the patient has had 
time to rest a while and regain a slight amount of strength, there 
being always a period of a few hours of weakness after the purga- 
tion, a warm sponge-bath may be safely given. The end of the 
third twenty-four hours is about the usual time for this first general 
bath : from the very first the hands, arms, neck, face, and legs should 
have been frequently bathed. From this time a daily sponge-bath 
of warm water, followed by alcohol, is to be given. The amount 
of comfort derived from this procedure is indescribable, and, if due 
care be taken not to chill the patient, not the slightest harm can 
come of it. The hair and teeth should receive attention from the 
very first. 

Flatulence. — This symptom is the most distressing one met with 
in the after-treatment of abdominal surgery. It accompanies, more 
or less, all cases, although in a very great many the amount is so 
slight that it is hardly noticed and requires no special attention. 
Where the woman's life is seriously threatened and she is eventually 
going to die, it is usually at its worst, and practically nothing can 
be done for its relief. 

Flatulence itself is capable of killing, and almost to the last 
it is impossible to say whether or not there is a chance of 
saving the patient : for this reason there should be no cessation 
in the efibrts for its dissipation. Usually it does not appear 
for from twelve to twenty-four hours, and in the majority of 
cases, where the bowels are opened at the end of forty-eight 
hours, it is permanently relieved. This being true, the great effort 
for its relief should be in the direction of securing a movement of 
the bowels. That form of flatulence which appears within twelve 
hours aftei* the operation is usually easily dealt with, and in itself 
has no great significance and need give no particular alarm. It is 
the variety which begins to show itself toward the end of the 
second twenty-four hours, which is accompanied with a refusal of 
the bowels to move, together with a quickening and weak pulse, 
which is to be dreaded : it most frequently means septic peritonitis 
and death. Little in the way of drugs, excepting purgatives, is 
worth administering. Large rectal enemata of water and turpen- 
tine, and the rectal tube introduced and at times allowed to remain 
in situ, will in some cases give relief. This is not very great, how- 



AFTER-TREATMENT IN GYNECOLOGICAL OPERATIONS. 669 

ever, and the practice has more theoretical than practical value. 
Puncturing the intestines through the abdominal wall is never 
justifiable : if it' is thought desirable to attempt to relieve the disten- 
sion by this source, a small incision should be made in the abdom- 
inal wall, a knuckle of gut caught up, opened, and either stitched 
to the abdominal wall or else closed bv a few sutures when the 
opening has accomplished its object. The same thing might readily 
be done through the original incision by removing a stitch or two 
and separating the edges of the wound quickly with a finger. The 
whole procedure can be carried out with the patient lying in bed and 
without an anesthetic. It is rare that anything can be hoped for 
from this direction, however, and it is seldom worth considering. 
Usually the result would be that only a single coil of intestine 
would be emptied, and nothing particular would be accomplished. 
The stomach-pump is a valuable aid in some of these cases, 
especially where the distension appears quite prominent in the 
epigastric region. Large quantities of fluids and air may be 
occasionally removed by its aid, and the distressed expression on 
a patient's face will clear up almost instantly after its successful 
use. After the first application the patient will in a few hours beg 
for a repetition, so great has been the relief obtained. 

As a matter of fact, unless the bowels can be gotten to move we 
can do little to permanently relieve this symptom, and even in those 
cases of sepsis in which the bowels have responded to the purgatives 
and enemata in a more or less satisfactory manner, the relief from 
the flatulence is not great, nor is it permanent, returning in a few 
hours, with the bowels obstinately constipated. At times, when 
nothing else will answer the purpose, turning the patient on the 
side will bring about the desired result. 

The causes of flatulence are varied. Too early administration 
of food where the stomach is so irritable that it does not perform 
its function of digestion and absorption, is a common cause. Milk, 
especially, of all foods, is most likely to favor its formation. 

It invariably accompanies sepsis, in which case it is most stubborn. 
Handling the intestines during the operation is supposed to be 
a common cause, but at times it is likely to follow in cases where 
the intestines have not been seen or have been handled the minimum 
amount, and at other times, when there have been partial evisceration 
and severe handling, even to the placing of stitches in the intestinal 
walls, there is no flatulence following the procedure. The real cause 



670 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

of flatulence is unknown, and its treatment is most unsatisfactory, 
except where the bowels can be gotten to move, when, as a rule, 
it disappears. 

Drainage-tube. — The care of the drainage-tube is one of the most 
important parts of the after-treatment. Should the tube be made 
of glass, each time it is cleaned the nurse or physician is practically 
dealing with an open wound, and just as great care should be mani- 
fested in its cleansing as is done at the operation itself: for the first 
few days the danger of infection is just as great. Should the tube- 
track become infected at this time, the chances are largely in favor 
of a septic peritonitis and death ; if the infection takes place later, 
when Nature has thrown out enough lymph to protect the peritoneal 
cavity, a suppurating pelvis may be the worst result. Under any 
circumstances infection is dangerous : if it does not end in death, it 
generally terminates in a fistula, which is more or less stubborn in 
healing. In cleaning a glass drainage-tube it is necessary to pass a 
long-nozzled syringe to the bottom of the tube in order to suck 
up the serum and blood which have accumulated in the pelvis. 
The syringe itself may be infected and carry the poison into the 
pelvis, or it may become infected as it passes the mouth of the 
tube. At each tube-cleaning the hands should be well washed 
with soap and water and disinfected with a bichloride-of-mercury 
solution. Clean towels should be placed about the tube, and the 
dressings over its mouth removed, so as to expose the open- 
ing. The syringe should be immersed in boiling water and 
the barrel filled and refilled several times ; it is then to be filled 
and refilled several times Avith a bichloride-of-mercury solution 
(1 : 1000) ; from this solution it is to be passed again into hot water 
and the mercurial washed away, when it is ready for use. The point 
of the syringe is passed to the bottom of the tube, and then with- 
drawn about a quarter or half an inch, so that when the piston is 
drawn the fluids in the pelvis will be sucked up, but not the tissue 
of the pelvis. If any clots or shreds of tissue remain in the pel- 
vis, the suction will draw them to the mouth of the nozzle, when by 
keeping up the suction they may readily be withdrawn. The syringe 
is to be used until the tube is perfectly dry. After using the syringe, 
it is to be first washed out thoroughly with hot water until the 
flow comes away perfectly clear and unstained, then the bichlo- 
ride-of-mercury solution is to be repeatedly drawn into it, and the 
syringe put away wet with the solution. It is to be placed imme- 



AFTER-TREATMENT IN GYNECOLOGICAL OPERATIONS. 671 

diately upon a clean towel kept for that purpose, and folded up so. 
as to remain unexposed until again required. Each time the tube 
is cleaned its mouth is to be well washed with a piece of cotton wet 
with a bichloride-of-mercury solution, and the wet cotton is to be 
passed down the tube as far as possible (an inch), so as to render its 
caliber thoroughly clean. The rubber-dam about the tube should be 
carefully cleansed of any drops of blood or serum which may have 
soiled it, and clean cotton is placed over the mouth of the tube. 
All this trouble may seem unnecessary, but any one familiar with 
the dangers of sepsis will appreciate its importance. A drop of 
blood or serum left about the mouth of the tube or in the syringe 
will quickly undergo decomposition. It is much easier to prevent 
sepsis than to cure it. 

Each time the tube is cleansed it should be twisted back and 
forth several times. The lymph which is thrown about the tube, 
penetrates the small perforations at its bottom, and if not broken 
up, and kept so by frequent rotation, becomes firm enough to cause 
considerable difficulty in the subsequent removal. This difficulty 
has been such a common one that several instruments have been 
devised for the express purpose of cutting the tube loose. If the 
simple precaution be observed of twisting the tube back and forth 
at each dressing, no such difficulty will ever arise. 

The drainage-tube should be allowed to remain in situ until 
such time as it is no longer needed for drainage. This time varies 
in different cases, and no hard-and-fast rule can be laid down 
for all. A few drachms of clear serum may always be found in 
the peritoneal cavity, and when the amount which can be drawn 
from the tube reaches two or three drachms at five or six hours' 
interval, and this fluid is clear or nearly approaches straw color, 
the time for the withdrawal of the tube has come. A drainage- 
tube should be cleansed as often as it becomes necessary, no atten- 
tion being paid to the shortness or length of time. Immediately 
following the operation it should be emptied every fifteen minutes 
or half hour. It should never be allowed to go sufficiently long to 
overflow and soil the dressings. As the quantity of fluid decreases, 
the interval of cleansing is lengthened, until by the end of twenty- 
four hours it is generally not necessary to clean it oftener than once 
in three hours. 

Sometimes in twenty-four hours the tube may be withdrawn, 
or it may be necessary to allow it to remain for a week : about 



672 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

three days is the average length of time. In withdrawing the 
tube it is only necessary, after removing all the dressings, to 
make traction upon it, meanwhile rotating it as it is drawn out. 
The same careful antisepsis is to be observed in removing as in 
cleansing it. A small piece of antiseptic gauze is placed over the 
opening left by the withdrawal of the tube, and its edges are drawn 
together with a strip of adhesive plaster. The dressings are replaced, 
and not disturbed again until the stitches are removed. 

In some cases the surgeon fears that the pelvis or certain parts of 
it may suppurate or that a fecal fistula may form, and yet the drain- 
age-tube is ready, from all appearances, to be withdrawn a day after 
the operation. Under these circumstances it is best to allow it to re- 
main for three or four days, cleansing it only often enough to have 
an idea of what is going on at its lower extremity — possibly twice 
in the twenty-four hours unless the symptoms indicate otherwise. 

Should suppuration occur, the tube is to be kept in place until 
the amount of pus discharged begins to diminish, when it may be 
withdrawn and the opening allowed to gradually contract. During 
the acute stage of suppuration the tube should be cleansed every 
few hours and washed out with boracic-acid solution : later, after 
it has been dispensed with, peroxide of hydrogen is the most effi- 
cient wash for cleansing and disinfecting the tube-track. The open- 
ing generally closes in a week or two, or if not, the condition be- 
comes chronic and a permanent fistula results- 
Should the drain be of gauze instead of glass, the care of it will 
be somewhat different. The gauze drains by capillary action, and 
keeps the dressings continually wet, so that it is necessary to change 
them frequently. The whole arrangement of the abdominal dress- 
ing is such that the parts about the drain may be changed with- 
out removing all. The one commonly used is that known as the 
Mikulicz drain. It consists of a gauze bag containing a number 
of pieces of gauze, the end of each piece protruding from its mouth. 
In withdrawing the drain the pieces are picked up with a pair of 
dressing forceps and withdrawn separately ; as they are removed 
the bag collapses, and is easier withdrawn than if the whole 
drain was removed together. In drawing out the bag care should 
be taken that no pieces of intestine or omentum follow, as at times 
is apt to be the case : should this occur the viscus is to be replaced 
at once with the forceps and the edge of the wound drawn together 
with the ligature which was placed for that purpose at the time 



AFTEB-TBEATMENT IN GYNECOLOGICAL OPEBATIONS. 673 

of operation, or by a strip of adhesive plaster, care being taken 
that intestine or omentum be not included between the lips of the 
wound. 

Dressings. — An ordinary case of abdominal section need not 
have the original dressing removed until the time has arrived to 
take out the stitches. Should a drainage-tube be in use, the dress- 
ing may become soiled, when it will be necessary to change it, or if 
the incision or the stitch-tracks suppurate, it will be advisable to 
remove the dressing, not only to replace it by a clean one, but in 
order to apply remedies to the suppurating parts. A full week 
should elapse before disturbing the stitches. Stitch-hole abscesses 
may arise before the stitches are removed or afterward. The 
stitches should be taken out on the eighth day unless suppura- 
tion has previously occurred, when it may become necessary to 
remove them immediately. This procedure is accomplished by 
picking up one of the strands of the stitch by the aid of a pair 
of hemostatic forceps, lifting the knot out of its bed, and exposing 
both strands of the stitch below the knot. The blades of a pair 
of scissors are opened, and made to include one of the strands 
as it dips down into the tissue; the scissors are pressed down 
into the skin at the same time that the knot is elevated by the 
forceps. This procedure exposes a portion of the ligature, which 
has been buried in the tissue, and which is white and clean and 
has not been infected. The ligature is cut in this uninfected 
area. As the cut end is drawn through the tissues in its removal, 
there is no danger of dragging infection with it, when if the stitch 
had been cut above the skin-surface a portion of contaminated suture 
would infect, in many cases, the suture-track. In this manner are 
caused stitch-hole abscesses which form after the stitches have been 
removed. After the one strand of the stitch is cut, the knot is to be 
drawm in the direction across the incision, not away from it. Should 
it be drawn away from the incision, there is an excellent chance that 
the skin-union will be separated at points, and possibly throughout 
its whole extent. 

After the stitches have been removed the parts about the incis- 
ion should be cleansed with a piece of cotton dipped in a solution of 
bichloride of mercury, care being taken not to disturb the line of 
union. The dried clots may be left alone, else in their removal 
some raw surface may be exposed. A small piece of antiseptic 
gauze is to be placed over the incision, and the parts held together 

43 



674 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

by several strips of adhesive plaster, a binder being placed over 
the whole. Usually no more attention need be paid to the 
wound. 

If the incision suppurates, it is best to remove the stitches at once, 
a,llow the superficial parts of the wound to separate, and treat the 
incision as an open wound by disinfecting and packing. The cicatri- 
cial tissue resulting from this method of healing will be the surer 
barrier to a future hernia. If stitch-hole abscesses exist, it is only 
necessary to provide for their drainage. Usually as the stitch is 
withdrawn the pus will flow from the opening left by its removal, 
and it may be necessary to empty the abscess once or twice a day 
by gently squeezing it, care being taken not to exert too much 
pressure : the abscess will, as a rule, heal within from two days 
to a week. A considerable rise of temperature and pulse may 
accompany these abscesses, but the symptoms disappear almost at 
once after drainage has been provided. While suppuration goes 
on the dressing should be changed twice daily and the parts thor- 
oughly cleansed. It should be treated, in fact, like any suppurating 
wound. If any of the cavities are very large, it may be well to 
inject them with peroxide of hydrogen or bichloride-of-mercury or 
other antiseptic solution. 

Hemorrhage, — For hemorrhage following an abdominal section 
there is but one treatment. As soon as the surgeon is reasonably 
certain that serious bleeding is going on, the wound must be opened 
and the bleeding vessel ligated. Attempts to apply any other treat- 
ment are useless, and the less time lost the more chance there will be 
of saving the patient. Care should be taken in re-opening the wound 
that everything is just as antiseptic as at the original operation. 

If a drainage-tube has been used, it will usually indicate that 
bleeding is taking place, but this is not to be depended upon 
for an indication as to how much blood is being lost. The abdo- 
men has been opened and found filled with clots when the tube pro- 
jecting into its cavity had been cleaned every ten or fifteen minutes, 
and it was supposed that all the blood had been withdrawn. Even 
if the tube does not indicate that a dangerous amount of blood is 
being lost, if the constitutional symptoms look strongly suspicious, 
the abdomen had better be re-opened and the bleeding vessel tied. 
The constitutional symptoms will be the same as those of con- 
cealed hemorrhage from any other cause. If the bleeding comes 
from torn adhesions, and is simply a free ooze, no alarm need be 



AFTEB-TBEATMENT IN GYNECOLOGICAL OPEBATIONS. 675 

felt concerning it. It matters not how free it maybe at first, it 
will last but a short while. The indications are to keep the drain- 
age-tube perfectly dry, so as to favor coagulation of the blood and 
consequent cessation of the bleeding. The oftener the tube is 
cleansed and the drier the pelvis is kept, the sooner will the hem- 
orrhage cease. 

If the patient, having rallied from her ether, with a good pulse 
and practically normal temperature, be found in the course of 
the next twenty-four hours to be showing indications of collapse, 
together with a rising pulse and a falling temperature, hemor- 
rhage will almost always be fouud to be at the bottom of the 
trouble. The pulse under these circumstances becomes feeble, 
and is rapid and running in character. The temperature and pulse, 
together with the general condition of lassitude and growing indif- 
ference, are almost pathognomonic of the condition. If the bleed- 
ing be allowed to continue, these symptoms gradually deepen, and 
the more advanced indications of collapse, such as great pallor, sigh- 
ing, and cold surface, supervene. 

Shock. — The symptoms of shock may readily be mistaken for 
hemorrhage, the difference being that in hemorrhage the indications 
do not begin for some hours after operation, while in shock they are 
present from the first. Otherwise, the two present so many points 
of likeness that it is at times difficult to say which is present. The 
indications for treatment in shock following abdominal section are 
exactly the same as for that condition from any other cause — dry 
heat applied to the whole surface of the body, care being taken not 
to burn the skin with the hot cans or bottles ; whiskey and am- 
monia. Strychnia is the most valuable of all drugs for this con- 
dition, and may be given freely without fear. It should be given 
hypodermically in doses of one-twentieth of a grain repeated every 
half hour for two or three hours, and then each hour until the 
patient is decidedly better or shows signs of muscular twitcliing. 
It is far better to take the chances of producing strychnia-poison- 
ing than to give too small a quantity. If the patient can be car- 
ried over the shock, it will be time enough afterward to attend to 
the poisonous symptoms. 

Sepsis. — The management of this complication will depend much 
upon the character and extent of the infection. A general pelvic 
and abdominal septic peritonitis following abdominal section is never 
cured : the patient invariably dies. For more than two days it is 



676 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

doubtful just Avbat is the trouble with the patient; in fact, one can- 
not be certain that there is anything seriously wrong. By the time 
it is reasonably certain that there is septicemia to deal with, the 
patient is beyond relief, and is dead before the end of the fourth 
twenty-four hours after the operation. Usually the condition of 
the patient immediately following the operation is fairly good, but 
within the first twenty-four hours the pulse gradually and almost 
imperceptibly creeps up until it reaches 110 to 120 beats to the 
minute. It is weak and inclined to be running. The temperature 
simultaneously ranges in the neighborhood of 100 or more degrees. 
The ether- vomiting is prolonged beyond the- usual limit of twenty- 
four hours, when most probably the stomach will have an interval 
of rest for six or eight hours before the secondary vomiting due to 
the septicemia sets in. 

During this interval of rest from vomiting the pulse grad- 
ually but steadily creeps higher and higher, becomes more rapid 
and weak, and finally thready. The temperature at the same 
time becomes more and more elevated. The abdomen becomes 
distended, due partly to flatulence and partly to the retention 
of the purgatives and nourishment. In spite of all efibrts to 
move the bowels, no indication of borborygmus or of passage of 
flatus can be obtained. The stomach finally begins to expel every- 
thing placed in it. The rectal enemas are promptly rejected. Pro- 
fuse sweating and cold creeps set in. The dull, heavy muscular 
pains of septic poisoning supervene. The patient becomes restless, 
tossing from one side of the bed to the other. The facial expression, 
which has been gradually becoming more and more anxious, deepens, 
and the patient assumes an altogether hopeless appearance. Prior 
to death the pulse becomes so rapid and weak as to be impercepti- 
ble : the temperature may rise even to 106° or 107°, and the body 
is bathed in a cold, clammy perspiration. The vomited matter is 
dark brown. 

No eflbrt should be spared to secure a passage of the bowels 
until the trouble has plainly manifested itself. 

Whiskey and strychnia should be given to the point of tolerance, 
many of these patients taking from a pint to a quart of whiskey in 
the twenty-four hours without showing signs of its constitutional 
effect. Quinine in large doses is a valuable adjunct to the manage- 
ment of these cases. The hypodermic needle and rectal enemas 
must for the most part be depended upon for the administration. 



AFTEB'TBEATMENT IN GYNECOLOGICAL 0PEBATI0N8. 677 

If at the end of sixty hours there is no longer doubt as to the 
complication, it is useless to make further effort, other than to ren- 
der the patient's death as easy as possible. Under these circum- 
stances opium is the one drug to depend upon. It will relieve the 
pain and suffering, and that is all it is in the power of the physician 
to do for his patient. Theoretically, the proper treatment would be 
to open the abdomen, irrigate it thoroughly and introduce a drain- 
age-tube. It would probably be best to do this as early as twenty- 
four or thirty-six hours after operation should by any chance the 
diagnosis be made, but even at this early period it is more than 
doubtful whether any good would be accomplished. When the 
abdomen is opened the condition found will be that of a general 
matting together of the pelvic organs and those loops of intestines 
and omentum hanging into the pelvis. An ounce or two of dark 
fluid will be observed on breaking up the adhesions. The only 
effect obtained will be to expose more surface to absorption by sepa- 
ration of the adhesions. If any good can be accomplished in this 
direction, it will be by providing free and continuous irrigation of 
the whole pelvic cavity for several days or until such time as the 
patient is convalescent. If the infection be introduced at the time 
of the operation, and be given twenty-four or thirty-six hours in 
which to develop, the case is practically hopeless. The diagnosis 
cannot possibly be arrived at earlier than at the end of forty-eight 
hours with any degree of certainty. 

Should a local suppuration occur about the pedicle or elsewhere 
in the pelvis and an abscess result, the condition is amenable to 
treatment and the patient will easily recover. The symptoms 
induced by the abscess will be the ordinary ones of septic infection, 
which, taken in conjunction with the knowledge obtained from 
the operation, will readily indicate their true cause. For the first 
few days the patient progresses favorably. Movements of the 
bowels are obtained in response to the purgatives and enemas, but 
not of a satisfactory character. The pulse remains high, from 100 
to 120 beats to the minute, but fairly good in character. The tem- 
perature ranges from 100° to 102°, or higher, with a daily evening 
elevation. The patient may at times reject her food, having little 
or no appetite. Her mental condition is clouded, and she com- 
plains of dull pains and cold creeps. Her general condition is 
heavy and lethargic. Night-sweats are present. The abdomen is 
more or less distended, and colicky pains are apt to disturb her in 



678 ^iV^ AMERICAN TEXT-BOOK OF GYNECOLOGY, 

consequence. These symptoms are of more gradual development 
than those of general septic infection of the pelvic cavity. At no 
time do they become so intense, and seldom threaten speedy death. 

The only proper treatment is to empty the abscess and drain 
the cavity after having washed it out. It may be necessary to 
re-open the abdomen to accomplish this. Frequently in these cases 
a drainage-tube has been used in the pelvis, and it is then most 
probably near the seat of the abscess. Under these circumstances, 
if the symptoms will allow of delay, it is best to wait for a few 
days, or even a week if necessary, in hopes that the abscess will 
rupture into the drainage-tube, which it generally will do. Should 
the temperature, pulse, and other symptoms become alarming at 
any time, the lower end of the incision had best be opened, and 
the abscess sought in the pelvis amid the adherent intestines and 
opened with the finger, care being taken not to invade, if possible, the 
general peritoneal cavity. If the pus be thoroughly washed away, 
the temperature and pulse will fall almost immediately to normal, 
and the other symptoms will disappear coincidently. Stimulation 
by whiskey, strychnia, and quinine is to be begun early and car- 
ried out freely, only stopping short of the physiological action of the 
drugs. Septic symptoms due to stitch-hole abscesses are to be treated 
as already described under the head of Dressings. 

Fistula. — These are either simple suppurating, fecal, or urinary. 
The simple suppurating fistula is the most common. It is generally 
due to an infected tube-track or to septic ligatures. The majority 
of fistulse close eventually without special treatment for, which 
reason they should be treated expectantly rather than by a sec- 
ondary operation. If they are caused by an infected ligature, 
they will not heal until the ligature has come away, when they 
usually close very promptly. Various methods have been pro- 
posed for removing the ligature through the fistulous track with- 
out re-opening the abdomen. A pair of small-bladed forceps may 
be passed into the opening and an attempt made to catch the offend- 
ing body : the introduction of pieces of twisted wire and various 
other devices have been adopted, with success in but exceptional 
cases. The silk will eventually work itself free and appear at the 
mouth of the fistula. Few fistulse remain open unless there is a 
foreign body present as the cause : the exception occurs in women 
who are probably suffering from tubercular or other general con- 
ditions. 



AFTER-TREATMENT IN GYNECOLOGICAL OPERATIONS, 679 

Under any circumstances the sinus should be kept clean and 
free from the discharges; at the same time the general health 
should be looked after, and if there is any condition such as 
tuberculosis present, it should be treated accordingly. Perox- 
ide of hydrogen diluted with water — half and half — or in its 
pure state is probably the best wash which can be used. It 
is to be passed, by the aid of a syringe, to the bottom of the 
fistula and allowed to regurgitate, the injection being kept up 
until it comes away clear and clean without any appearance of 
froth : it would be well to wash the sinus out several times daily, 
the dressings being changed frequently enough to keep the parts 
clean. 

It is proper to wait from three to six months, or even longer, 
before attempting any radical procedure. The operation necessitates 
opening the abdominal cavity, with all the chances of infecting the 
peritoneum with the discharges of the sinus. Should the operation 
be undertaken, the parts must first be thoroughly disinfected, and 
the sinus washed out with peroxide of hydrogen and a solution of 
bichloride of mercury. The abdomen is opened, the adhesions 
broken up to the bottom of the fistula, and the ligatures removed : 
the walls of the fistula should be separated with the scissors and 
curetted away as far as possible. Should no ligature be found, the 
walls of the sinus must be thoroughly destroyed. In closing the 
abdomen a drainage-tube must be introduced for a few days in 
order to guard against possible suppuration. 

Nothing can be done for chronic fecal fistulse short of an ope- 
ration, except to keep the parts clean. It is not always advis- 
able to attempt an operation in these cases, for the reason that 
the opening in the bowel is often so low down in the rectum 
that it is impossible to bring the parts within reach so that sutures 
can be properly placed : in addition, the tissues of the gut are often 
so badly disorganized that stitches will not hold, and a resection 
would be necessary, when from the low position of the opening this 
would be impossible. If the operation is undertaken, the parts 
must be thoroughly cleansed and disinfected ; the bowels should be 
purged and the rectum washed out by an enema. After invading 
the abdominal cavity the adhesions between the coils of intestines 
are to be carefully separated down to the opening in the bowel. 

Occasionally in old chronic cases the fistula can be dissected out 
as a complete tube down to the intestinal opening, in which case 



680 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

there would be a minimum danger of infecting the peritoneal cavity. 
Under any circumstances the edges of the fistula are to be freshened 
and turned into the gut, sutures being placed so as to retain the 
edges in apposition. If the opening is sufiiciently high to allow 
of a resection of the bowel, this may become necessary, provided 
it cannot be closed. Should it not be possible to close the 
hole or to resect, a drainage-tube must be placed so as to drain 
the immediate vicinity of the injured bowel, anid the tube cleansed 
every fifteen minutes, to allow no spread of infection until sufii- 
cient lymph has been thrown about the seat of danger to protect 
the peritoneal cavity : in the mean time enough opium is given to 
keep the bowels quiet. 

The operation for chronic fecal fistula is a tedious and dangerous 
one, and often results in failure or in disaster. It is the only hope 
of relief, however, and it is justifiable to take considerable risk with 
the hope of gaining a cure. 

The primary treatment of fecal fistula is one of rest. Should the 
fistula occur three or four days after operation, enough lymph will 
have been thrown out to protect the general peritoneal cavity, 
and there will be little danger. Should it be discovered during the 
first few hours, while cleaning the drainage-tube, the tube must be 
cleansed at intervals of not longer than fifteen minutes, and the 
bowels kept quiet by the use of opium for three or four days at 
least. When the bowels have once opened, they should not be 
allowed to again become constipated, but daily evacuation should 
be secured by the use of laxatives. 

In the course of a week the tube may be safely withdrawn, and 
the fecal matter allowed to flow through the track formed by the 
lymph. As long as the tube is in place the opening will not close, 
but as soon as it is removed the parts begin to contract, and grad- 
ually the flow of fecal matter becomes less and less, until, finally in 
a few weeks it has ceased altogether. Most fecal fistulse will close 
spontaneously if treated properly from the first. 

Hernia. — This is one of the common sequelae of abdominal sec- 
tion, and is due to a failure of union between the cut edges of the 
muscles and fasciae. The hernia usually does not appear for some 
weeks after the woman is out of bed, and then only as a small 
protrusion at one point, from which it gradually spreads, until, if 
neglected, it at times occupies the whole of the original incision. 
As a prophylactic measure against this accident the longer the 



AFTER-TBEATMENT IN GYNECOLOGICAL OPERATIONS, 681 

patient is kept in bed after her operation the better : too early get- 
ting up puts a strain on the newly-united incision and predisposes 
to hernia. When the hernia has once appeared, but two courses 
are open— either to use support at the opening and if possible pre- 
vent it from becoming larger, or to perform a secondary operation 
for its cure. A properly-fitting truss will keep the intestines back 
and to a great extent render the woman comfortable, but there is 
no chance whatever of the opening ever closing if left to itself. 

Fig. 360. 



Sutures in place for the Repair of Ventral Hernia. 



In making the incision, great care must be observed in opening 
the abdominal cavity at the seat of the hernia, for the reason that 
the intestines are very apt to be adherent to the sac. The anatom- 
ical relations are all destroyed, and there is no certain guide as to 
where the knife is about to enter the peritoneal cavity. After the 
abdominal cavity is opened the old incision should be split to the 



682 AJSr AMERICAN TEXT-BOOK OF GYNECOLOGY. 

full extent of the hernia both above and below. The peritoneal 
and adventitious tissue covering the edges of the muscle and fascia 
completely around the opening must be trimmed away with the 
scissors and knife, and the redundant portions of the sac resected. 
The edges of the several tissues are brought into apposition and 
the wound closed in the usual way after an abdominal section. 

Various methods of repairing hernias have from time to time 
been used with varying degrees of success, but all the indications are 
met by the above method, especially if an extra and separate row 
of sutures be placed in the muscles and fascia in order to secure 
and retain their coaptation. Either catgut or silk may be used for 
this purpose. If the silk is surely aseptic, it is preferable, as it 
gives a permanent support to the tissues, while the catgut is apt to 
become so weakened by absorption within a few days as to be of no 
value. Subsequently the patient should be kept upon her back for 
not less than four weeks, to allow of thorough healing. Should the 
buried silk sutures suppurate, it is due to faulty technique, and the 
silk must be removed before the resulting fistula will heal. 

The usual length of time for a patient to remain in bed following 
an abdominal section is at least three weeks. During the early 
part of the fourth week the patient may be allowed to sit up in bed, 
and by the end of the week she may begin to go about her usual 
duties. It is well, however, that she make a semi-invalid of herself 
for some weeks or more where this is possible, and secure the addi- 
tional rest from work and worry. For six months or a year after 
the operation an abdominal binder should be worn, at the end of 
which time it may gradually be dispensed with. The neglect of 
these precautions often results in a very considerable amount of 
future discomfort to the patient. 

Every woman who has had both uterine appendages removed 
suffers from symptoms of the menopause. Generally these are 
more stormy than those accompanying the natural menopause, but 
are proportionately shorter. Until this change is fully established 
the patient will not receive the full benefit of the operation. The 
condition requires treatment, and the indications are to be met as 
they arise in the way such symptoms are usually met in the natural 
menopause. The phenomena are essentially nervous, and the indi- 
cations are for general tonics and nerve-sedatives. 

As has been already noted, the infection which gives rise to the 
disease requiring an abdominal section in pelvic inflammation, pro- 



AFTEB-TBEATMENT IN GYNECOLOGICAL OPEBATIONS. 683 

ceeds from the vagina or the uterus into the Fallopian tubes. The 
removal of the uterine appendages does not always cure the case, 
but is merely the necessary preliminary step. Some cases are com- 
pletely cured by the changes which go on in the uterus incident to 
the menopause, but in others, in spite of this, the womb remains 
enlarged, heavy, and engorged, and the leucorrheal discharges and 
hemorrhages remain just as profuse as before the operation. These 
eases require local treatment of the diseased uterus ; otherwise a sat- 
isfactory result is not usually obtained except after a long interval. 
The womb should be thoroughly curetted, and the case treated as is 
proper in a case of endometritis and subinvolution. At times, 
however, the prolonged effect of the menopause is too much for 
even these cases, and they eventually, after several years, are re- 
lieved of their symptoms without any local treatment ; other cases 
require that eventually the womb be removed. 

Plastic Opekations. 

The after-treatment of plastic operations for the repair of the 
perineum and cervix resolves itself into rest and cleanliness. The 
shortest time the patient should be kept in bed is two weeks, after 
which she may take another week in getting up and about. As in 
abdominal section, the longer she remains in bed the better for her, 
and where a patient can be made content, a month is not too long a 
time, especially for prolapse cases. If a gauze tampon has been 
introduced into the vagina, it should be removed within forty-eight 
hours, and need not be renewed. A warm vaginal douche of 
boracic acid should be administered daily, care being taken not to 
make any pressure on the points of suture. The douche should be 
used for the purpose of cleanliness, after which a single strip of 
gauze an inch or two in width may be passed if desired into the 
cul-de-sac with the aid of dressing forceps. This accomplishes the 
desired drainage with the minimum interference with the seat of 
operation. Especial care must be taken in this regard when cat- 
gut sutures have been introduced. 

In cases of uterine curettement, if the cavity of the womb has 
been packed with gauze, the packing should be removed at the 
end of forty-eight hours and the vagina thoroughly cleansed by 
an antiseptic douche. Afterward an antiseptic vaginal douche 
should be administered daily. If instead of the gauze a drain- 
age-tube has been introduced into the uterus at the time of ope- 



684 AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

ration, it should be removed daily, cleansed, and replaced. This 
can readily be accomplished by placing the patient in the left 
lateral position in her bed and introducing a perineal retractor. 
The cervix being exposed and steadied by drawing it down 
with a tenaculum, the drainage-tube is caught in a pair of dress- 
ing forceps, withdrawn from the uterus, cleansed, and at once 
replaced. It will be perfectly easy before replacing the tube to 
wash out the uterus with an antiseptic solution by the aid of a David- 
son's syringe with a rectal nozzle attached. 

When a cancerous cervix has been removed by the aid of the 
curette and scissors, the tampon, which has been placed in great 
part to control the subsequent bleeding, should be allowed to re- 
main for forty-eight hours, at the end of which time it may be 
removed. This is done with the patient lying in the left lateral 
position in her bed ; the vagina and wound are then cleansed and 
disinfected, and a fresh tampon re]3laced, provided there be any 
signs of bleeding. If there be no bleeding, a single strip of 
gauze to provide for drainage is all that will be required. This 
should be renewed daily after each antiseptic douche. 

The bladder is to be catheterized only in case of necessity, and 
unless there has been an operation on the anterior wall of the 
vagina the instrument will rarely be needed. In cases of repair of 
vesico- vaginal fistulse, the bladder must be kept empty, either by 
frequent use of the catheter or by a self-retaining catheter for four 
or five da^^s, or until such time as it is safe to allow the urine to 
accumulate and the bladder to empty itself. The bowels may in 
all cases be opened the day following the operation ; a daily passage 
should be secured thereafter ; this holds equally good for tears of 
the perineum involving the sphincter. A dose or two of magnesium 
sulphate should be administered, and as soon as there is any mani- 
fest desire for defecation an enema should be at once given, so as to 
secure as easy and as soft a passage as possible. If bleeding occurs 
after an operation, it is best that it should be given an opportunity 
to stop of its own accord. This usually occurs, but should it persist, 
hot vaginal douches may be given, and if these do not control it 
resort to a vaginal tampon may be necessary, even though it spoil 
the operation. The tampon should only be used as a last resort : 
it will rarely be needed. 

Except in cases of lacerated perineum where the sphincter is 
involved, or in cases of recto- vaginal fistulse, the patient may be 



AFTEB-TBEATMENT IN GYNECOLOGICAL OPERATIONS. 685 

allowed anything to eat or drink she may desire. It is just as 
well in these two injuries to confine the diet to such articles 
as will leave little residue, so that there shall be as small an 
amount of fecal matter as possible. It will not be necessary to 
restrict the diet for more than four or five days. The stitches in 
plastic operations should be removed on the seventh or eighth day, 
after which tim.e nothing in the way of treatment is necessary, 
except to see that the vaginal douche be given daily and that 
the bodily functions act properly. If a combined operation for the 
repair of the cervix and perineum has been performed, great care 
will have to be exercised in removing the stitches from the cervix, 
lest the union of the perineal wound be disturbed. For this reason 
the stitches in the cervix at the time of operation should be allowed 
to remain long and should be shotted. If this precaution be ob- 
served in placing the sutures, it will be easy subsequently to remove 
them by making traction upon the long sutures, and thus bring- 
ing the cervix into view, requiring a minimum amount of stretching 
of the perineum with the perineal retractor. The patient should 
be placed on a table in the dorsal position for their removal. If 
the same precaution be observed in regard to the placing of the 
stitches in the perineum, no difiiculty will be met with in their 
removal. So great is the facility with which this can be done that 
even the nurse can be trusted with the removal of the perineal 
stitches. Should there be much discharge from the parts, a bichlo- 
ride-of-mercury or a permanganate-of-potash douche may be sub- 
stituted for the boracic-acid one, and it may be given two or three 
times daily. This is especially necessary in the after-treatment 
of vaginal hysterectomies. 

The after-treatment of this operation, if performed throughout 
with catgut, is practically similar to that of plastic operations, 
greater care in regard to details being, however, necessary on 
account of the more profuse discharges. In cases where the 
stumps are stitched into the vagina, they subsequently come away 
by sloughing. The vaginal tampon placed at the time of operation 
should be removed on the third day and an antiseptic vaginal 
douche given. Unless there be considerable oozing of blood from 
the wounds, the tampon need not be replaced. Sloughing of the 
stump begins to manifest itself in about four days by a gradually 
increasing and foul-smelling discharge. In the course of ten 
days or two weeks the sloughing stump will have separated, and 



686 AN AMERICAN TEXT-BOOK OF GYNECOLOGY. 

the raw surface gradually heals by granulation and contraction. 
During the time of the suppuration the patient is mentally dull 
and sluggish; the temperature and pulse will be found slightly ele- 
vated, and there will be a loss of appetite evidenced. She is, in 
fact, suffering from a mild form of septic infection due to absorp- 
tion of the purulent discharges from the wound. This discharge 
is the greater where catgut has been used, as is always the case 
where this material has been employed in plastic operations. For 
these reasons it is the more important, in order to secure the com- 
fort and possible safety of the patient, that greater attention be paid 
to local disinfection and cleanliness. Vaginal douches should be 
used several times daily. Where silk has been used for ligatures 
and the stumps have been stitched in the vagina, the ends should 
be allowed to remain long, hanging from the vulvar orifice, so that 
when the sloughing takes place they may be removed by gentle 
traction. This traction should be applied daily with extreme care 
and gentleness until they have been removed. 

If the operation be performed by placing clamps upon the broad 
ligaments, these should be removed within thirty-six to forty-eight 
hours, when all danger of hemorrhage will have ceased. The han- 
dles of the clamps are to be loosened, the blades gently separated 
sufficiently to dilate the track in which they are imbedded, so as to 
facilitate their easy withdrawal. If, in withdrawing them, resist- 
ance is met at any point, they may be rotated back and forth and 
in their long axis, great care being observed not to use more force 
than is absolutely necessary to free them. On their withdrawal a 
vaginal antiseptic douche is given, and a single strip of gauze car- 
ried to the cul-de-sac for the purpose of drainage. 

Should a ureter have been included in either the ligatures or 
clamps during the operation, symptoms of uremia will quickly 
develop, and the patient in most cases will be lost. For the first 
few days it will be uncertain whether the patient is suffering 
from the shock of the operation, septicemia, or uremia. By 
the time the true cause of the trouble is determined with rea- 
sonable certainty the patient will probably be beyond help. The 
symptoms which will lead one to suspect this condition are a dimi- 
nution in the quantity of urine passed, the elevation and rapidity 
of the pulse and temperature, the low mental condition, together 
with restlessness and anxious expression of the countenance, — all 
beginning early. The diminution of the quantity of the urine is 



AFTEB-TBEATMENT IN GYNECOLOGICAL OPEBATIONS. 687 

the only one of all these symptoms pointing directly to the kid- 
ney as the seat of the trouble ; and when it is considered that the 
amount of urine secreted after an operation is under all circum- 
stances exceedingly small in the first twenty-four or forty-eight 
hours — often being less than twenty ounces in tke twenty-four 
hours — it will be seen of how little practical value this symptom 
really is. 

If the condition be diagnosed, the proper treatment consists in 
removing the clamps or ligature and freeing the ureters. Should 
the ureters have been cut in addition to having been clamped, 
their cut ends may be freed from the compressing force and turned 
into the vagina ; if the patient recover, at a subsequent operation 
the ureters may be turned into the bladder or the corresponding 
kidney be removed. The extreme danger of hemorrhage following 
the removal of the forceps or ligatures sufficiently early in these cases 
to repair the damage, to say nothing of the even greater dangers 
of septic infection during the necessary and most difficult manipu- 
lations, renders total extirpation of the kidney on the affected 
side a much safer and more promising operation. If there is any 
uncertainty as to which side is involved, catheterization of the ure- 
ters is our only method of determining this question. This proce- 
dure is valuable in excluding the ligature of one or both ureters as 
a possible cause of the symptoms. 

Should the bladder have been opened during the operation, and 
for any reason remain unclosed, great care should be taken not 
to allow any accumulation of urine. For this purpose a self-retain- 
ing catheter should be introduced, and retained in place until all 
chance of spontaneous closure is passed. If the opening remains 
permanently, subsequent operation must be made for its closure, it 
being treated in the interim as an ordinary case of vesico- vaginal 
fistula. 



INDEX. 



ABDOMEN, distension of, by ovarian 
XA. tumor, 582 

method of opening, 504 
sterilization of, 77 
Abdominal fistula, 516 
hysterectomy, 392 
incision, closure of, 79 

closure when the walls are thin, 80 

method of enlarging, 78 
operations, closure of the incision in, 79 

dressing the wound, 80 

immediate, preparations for, 76 

instruments required in, 77 

long incision in, 79 

preparatory treatment of, 75 

technique of, 75 
section, after-treatment of, 660 
wall, short incision in, 77 
wound, Pryor's method of closing, 311 
Abnormality in position of uterus, 142 
of the cervix uteri, 142 
of the Fallopian tube, 142 
of the hymen, 135 
of involution of the uterus, 125 
of the ovary, 143 
Abortion, coagula in menstrual discharge 
as proof of, 91 
solicitation of patients for, 102 
tubal, 525 
Abscess, intra-peritoneal, 455, 461 

physical signs of, 473 
labial, 170 
of the urethra, 617 
of the vulva, 178 
of the vulvo-vaginal glands, 169 

treatment of, 170 
ovarian, 449, 456, 468 

diagnosis of, 478 

prognosis of, 484 
pelvic, 463, 480, 481, 499, 611, 677 

cause of death in, 485 

coeliotomy for, 542 

drainage of, from vagina, 498 

treatment of, 502, 678 

vaginal puncture of, 500, 502, 542 
-sacs opening into bowel, 499 
tubo-ovarian, 457 
Absence of the clitoris, 135 
of the Fallopian tube, 142 
of the genital organs, complete, 131 
of the internal genital organs, 131 
of the labia majora, 135 
of the nymphse, 135 
of the ovary, 143 

44 



Absence of the pedicle in broad-ligament 
cyst, 604 
in parovarian cyst, 604 

of the uterus, 137 

of the vagina, 136 
Absorbent cotton, sterilization of, 67 
Accidents during operation for fibromyoma, 
434 

during removal of ovarian cyst, 607 
Adenoma, benign, of the uterus, 209 

malignant, of the uterine mucous 
membrane, 382 

of the ovary, 565 

papillary, of the uterus, 210 
Adherent omentum, disposal of, 434 

retrodisplaced uterus, reposition of, 
296 

salpingitis, 453 
Adhesions, bread-and-butter, 461 

from electrical treatment, 428 

in fibroids of the uterus, 428 

in ovarian cysts, 592 

of the intestines, 505 

of the labia, 165 

treatment of, 166 

of the omentum, 504 

of ovarian cysts, 575 

of the ovary, 460 

prevention of, after ovariotomy, 613 

separation of, 428 

in ovariotomy, 600 

spider-web, 459, 460 

vascular, separation of, 608 
Adhesive vaginitis, 195 
Adipose tumor of labium, 183 
After-treatment of coeliotomy, 660 

of curettage of the uterus, 233 

of plastic operations, 683 
Alexander's operation, 306, 308, 317, 332 

indications for, 309 
Allison gynecological table, 19 
Amenorrhea, 98, 530, 537 

apparent, 94 

causes of, 98 

comparative, 98-100 

complete, 98 

diagnosis of, 100 

electricity in, 103 

in atresia of the vagina, 191 

prognosis of, 101 

relation of marriage to, 105 

secondary, 101 

treatment of, 102 
Amputation of the cervix, 213, 332 

689 



690 



INDEX. 



Amputation of the cervix, after-treatment 
of, 377 
by the galvano-cautery, 374, 378 
by the Paquelin cautery, 379 
high, 376 
partial, 371 
simple, 371 

Sims's operation for, 239, 240 
wedge-shaped, 238, 271, 373 
with the ecraseur, 374 
of the clitoris, 165 
of the hypertrophied cervix, 283 
of the uterus, supra-pubic, 430, 431 
vaginal, of the inverted uterus, 350 
Anatomy, topographical, of the round liga- 
ment, 310, 311 
of the endometrium, 202 
Anesthesia, 31 

during examinations, 46 
room for the administration of, 59, 60 
Angioma of vulva, 184 
Anomalies of the female generative organs, 

130 
Anteflexion, 278 

complicated with the menopause, 286 
with hypertrophy, 281 
with retroversion, 280 
treatment of, 283 
pathology of, 281 
symptoms of, 279 
treatment of, 282 
Anterior colporrhaphy, 332 

Emmet's operation for, 332, 335, 

338 
Stoltz's operation for, 332, 336 
contraindication to, 337 
Anteversion, correction of, by distended 
bladder, 128 
pathological, 278 
Antisepsis in gynecological operations, 56 

of the hands, 56 
Apoplectic ovum, 528 
Appendicitis, 161 

Application of carbolic acid to the cervix, 
238 
to the endometrium, 285 
of caustics, cicatricial stenosis of the 

cervix from, 240 
of ichthyol to the endometrium, 215 
to the vaginal mucous membrane, 
301 
of iodine to the endometrium, 215, 226, 
233, 242, 284, 301 
to the vaginal vault, 494 
of ligatures in removal of fibroid ute- 
rus, 421 
to uterus, method of making, 215 
Applicator, uterine, 39, 215, 225 

Emmet's, 40 
Apron of the Hottentot, 135 
Areolar cyst of ovary, 563 
Arnold's sterilizer, 64, 66 
Arrangement for office examination and 

treatment, 21 
Artificial feciftidation, 128 
apparatus for, 129 



Ascites, 159, 160, 586 

complicating ovarian cyst, 578 
from ovarian carcinoma, 395 
Ascitic fluid, properties of, 593 
Asepsis in gynecological operations, 56 
Aspiration of ovarian cyst, 593 
Aspirator, 53 

Assistant supporting legs, 72 
Assistants, responsibility of, 61 
Atheromatous changes in cyst of ovary, 566 
Atresia of the cervix, 240 
of the hymen, 135, 188 
of the urethra, 615 

treatment of, 615 
of the vagina, 136, 187 
causes of, 187 
course of, 189 
prognosis of, 192 
symptoms of, 190 
treatment of, 192 
varieties of, 189 
Atrophic endometritis, 208, 212, 213, 232 
Atrophy of the ovary, 101 

of the uterus, 320 
Aveling's repositor, 350 
Axial rotation of cyst of ovary, 576 

BALDY'S irrigating tube, 74 
Ball pessary, 330 
Bartholini's glands, inflammation and ab- 
scess of, 169 
Bathing after coeliotomy, 667 
Benign adenoma of the uterus, 209 

hypertrophies of the endometrium, 363 
Bicornate unicervical uterus, 140 
uterus, 139 

pregnancy in, 584 
Bilateral hermaphrodism, 132 
incision of the cervix, 240 
laceration of the cervix uteri, 246 
Billroth's method for exstrophy of the 

bladder, 625 
Bimanual examination, 28 

in the lateral position, 31 
palpation of the uterus, 28, 224 
rectal palpation of the pelvis, 30 
recto-vaginal palpation of the uterus, 

31 
replacement of retroflexed uterus, 290, 
293 
Bipartite bladder, 622 
Bladder, carcinoma of, 647 
prognosis of, 650 
care of, after coeliotomy, 665 
congenital malformation of, 622 
distension of, resembling ovarian cyst, 

590 
double, 622 
exstrophy of, 623 

Thiersch's operation for, 624 
treatment of, 624 
inversion of, 652 
diagnosis of, 652 
symptoms of, 652 
treatment of, 653 
irrigation of, 636 



INDEX. 



691 



Bladder, method of sounding, 643 
neoplasms of, diagnosis of, 649 
prognosis of, 650 
symptoms oi^, 648 
treatment of, 650 
palpation of the interior of, 52 
polyp of, 648 
sinus of, 517 
tuberculosis of, 638 
diagnosis of, 639 
pathology of, 638 
prognosis of, 640 
treatment of, 640 
vascular-papillomatous fibroma of, 647 
wound of, 434, 506 
care after, ^'o^ 
during operation for ovarian cyst, 

610 
during vaginal hysterectomy, 687 
Blood-vessels in intraligamentary fibroids, 

426 
Blunt curettes, 225 
Boiled water for operations, 60 
Boracic-acid douche for bladder, 651 
Bowels, care of, after coeliotomy, 663 

after colpo-perineorrhaphy, 341 
after vaginal hysterectomy, 391 
depletion of, in pelvic inflammation, 

487 
incomplete preparation of, as a cause 

of sepsis, 432 
paralysis of, after coeliotomy, 433, 434 
Bozeman's uterine dressing forceps, 40 
Braided silk ligature, 422 
Brandt's method of replacement of the ute- 
rus, 296, 308 
Braun's colpeurynter, 329, 348 
intra-uterine syringe, 226 
Bread-and-butter adhesion, 461 
Brewer's speculum, 41-43 
Broad-ligament cyst, 559 

absence of pedicle in, 604 
adhesions in, 602 
Broad ligament, microcysts of, 560 

papillomatous disease of, 395 
Bulb syringe, 226 

Byford's lateral vaginal retractor, 46 
uterine dressing forceps, 39 
uterine elevator, 37 

CABINET, gynecological, 20 
Calcification of fibroid tumor of uterus, 
403 
of ovarian cysts, 566 
fibroid, 569 
Calcified corpus luteum, b^^ 
Calculus of the ureter, 658 
vesical, 641 

diagnosis of, 643 
etiology of, 642 
prognosis of, 644 
symptoms of, 642 
treatment of, 644 
Carbolic acid, application of, to the cervix, 
238 
to the endometrium, 285 



Carcinoma of the bladder, 647 
prognosis of, 650 
of the body of the uterus, 363, 381 
diagnosis of, 384 
symptoms of, 382 
treatment of, 385 
of the cervix, 364 

constitutional treatment of, 381 

course of, 368 

curettage of, after-treatment of, 684 

diagnosis of, 368 

palliative treatment of, 379 

radical treatment of, 370 

relief of fetid discharges in, 380 

of hemorrhages in, 380 
use of caustics in, 380 
incipient gastric, 87 
incipient, of the uterus, 209 
of the ovary, 393, 570 
treatment of, 396 
periurethral, 354 
of the ureter, 658 
of the urethra, 354, 618 
of the vagina, 356 
diagnosis of, 357 
etiology of, 356 
operative treatment of, 358 
palliative treatment of, 358 
symptoms of, 357 
of the vulva, symptoms of, 354 
treatment of, 354 
Carcinomatous infiltration, extent of, 370 
Care of glass drainage-tube, 70 
Caruncle, urethral, 617, 619 

as a cause of sterility, 126 
medullary sarcoma of, 353 
Case-book, 18 

Case for instruments, 59, 64 
Caseous tuberculosis of the peritoneum, 159 
course of, 160 
diagnosis of, 161 
prognosis of, 162 
symptoms of, 160 
treatment of, 162 
Catarrhal salpingitis, 449, 457, 465 
diagnosis of, 473 
physical signs of, 471 
symptoms of, 464 
Catgut ligature, 339, 388, 391, 603 
sterilization of, 66 
suture, 310, 313, 332, 336, 339, 340, 
377, 389, 418, 506, 596, 609, 
614, 682 
Catheter, care of, 634 
ureteral, 634, 639 
Kelly's, 657 
use of, after coeliotomy, ^^b 
Catheterization of the bladder, 251 
of both ureters, 658 
of the Fallopian tubes, 498 
of the ureters, 656 
Cauliflower epithelioma of the cerWx, 365 
Caustics, the use of, in carcinoma of the 

cervix, 380 
Cauterization of pedicle in ovarian cyst, 603 
Cautery, galvano-, 374, 378 



692 



INDEX. 



Cautery, galvano-, use of, in carcinoma of 
the vagina, 358 
Paquelin's, 354, 364, 379, 389, 420, 609, 
602 
Cellulitis, 449, 453, 462, 470 
diagnosis of, 482 
pelvic, 437, 611 
Cervical mucous membrane, inflammation 

of, 235 
Cervicitis, polypoid, 238 
Cervix, amputation of, 213, 332 ■ 

by the galvano-cautery, 374 
high, 334, 376 

after-treatment of, 377 
by the galvano-cautery, 378 
by the Paquelin cautery, 379 
partial, 371 
simple, 371 
Sims's operation, 239 
wedge-shaped, 238, 371, 373 
with ecraseur, 374 
application of carbolic acid to, 238 
bilateral incision of, 240 

laceration of, 246 
carcinoma of, 364 

constitutional treatment, 381 
course of, 368 
curettage in, 379 

after-treatment in, 684 
diagnosis of, 368 
palliative treatment, 379 
radical treatment of, 370 
relief of fetid discharges in, 380 

of hemorrhages in, 380 
use of caustics in, 380 
cicatricial stenosis of, 240 
conical, 280 

cystic degeneration of, 236, 238 
dilatation of, 283, 284, 285, 286 

by graduated sounds, 224 
diphtheritic deposits upon, 370 
division of, in sterility, 128 
ectropion of the, 240 
elongation of, 280 
epithelioma of, 364 
erosions of, 238, 290 
fibroid polypi of, 398 
fissure of, 245 
follicular cysts of the, 237 
glandular hypertrophy of, 240 

polypi of, 240 
hypertrophy of, 240 

amputation of, 283 
incision of, 213, 408 
infection following plastic work upon, 

219 
infravaginal elongation of, 334 
laceration of, 245 

immediate operation for, 246 
incision in the angles of, 249 
knife for denudation in the opera- 
tion for, 249 
method of denudation in the opera- 
tion for, 249 
operation for, 249 
symptoms of, 246 



Cervix, laceration of, treatment preparatory 
to operation, 248 
muriform polypi of, 398 
normal mucous membrane of, 204, 205 
papillary erosion of, 237 
polypi of, 236 

rapid dilatation of, 223, 408 
scarification of, 248, 490 
Sims's amputation of, 240 
splitting of the, 50 
supravaginal hypertrophy of, 333 
symptoms of, 334 
treatment of, 334 
total extirpation of, 336 
tuberculosis of, 147 
diagnosis of, 149 
treatment of, 149 
unilateral laceration of, 247 
uteri, abnormality of, 142 
Cessation of menstruation, the time of, 85 
Chancre of the vulva, 174 
Chancroid of the vulva, 175 
Chair, the Indianapolis gynecological, 20 
Chemical antisepsis, k)Q 
Chloride-of-zinc pencils, treatment of endo- 
metritis with, 214 
Chloroform, administration of, 598 
Chorionic villi, 537 
Cicatricial stenosis of the cervix, 240 

from application of caustics, 
240 
Clamp method of removal of ovarian cyst, 

603 
Cleansing of sponges after operation, 67 
Climate, effect of, upon menstruation, 83 
Clitoris, 164 

absence of, 135 
amputation of, 165 
cystic tumors of, 182 
hypertrophy of, 165 
congenital, 135 
scirrhous carcinoma of, 353 
tumor of, 183 
Cloaca, recto-vaginal, 136 
uro-recto-vaginal, 136 
Closure of the abdominal incision, 79 

of the deep perineal and vaginal tear 

in lacerated perineum, 262 
of the rectal part of the rent in lace- 
rated perineum, 262 
of the sphincter in lacerated perineum, 
262 
Coagula in the menstrual flow as a proof of 

abortion, 91 
Cocaine hydrochlorate, operation under, 

263 ' 
Cocci from an empyema, 218 
Coccygodinia, 184 
prognosis of, 184 
treatment of, 184 
Coccyx, extirpation of, 185 

palpation of, 26 
Coeliotomy, 415 

administration of drink after, 662 
of food after, 662 
of purgatives after, 663 



INDEX. 



693 



Coeliotomy, after-treatment of, 660 
bathing after, 667 
care of bladder after, 665 
dressing after, 673 
during acute peritonitis, 512 
fecal fistula after, 679 
flatulence after, 668 

cause of, 669 
for fibro-myomata, cause of death after, 

431 
for pelvic abscess, 542 
hemorrhage following, 674 
hernia after, 680 
in ectopic gestation, 546 
rest after, 660 
shock after, 675 
suppurating fistula after, 678 
suppuration of the wound after, 674 
uremia following, 667 
vomiting following, 661 
Colic of the Fallopian tubes, 111 

uterine, 114 
Collodion, dressing the abdominal wound 

with, 80 
Colon, wounds of, 434 
Colpeurynter, Braun's, 329, 348 
Colpo-perineorrhaphy, 332 
Emmet's operation, 330 
Hegar's operation, 330, 338 
Colporrhaphy, anterior, 332 

Emmet's operation, 332, 335, 338 
Stoltz's operation, 332, 336 
contraindications to, 337 
Combined operation, 341 

removal of stitches in, 685 
Comparative amenorrhea, 98-100 
Complete amenorrhea, 98 
hysterectomy, 430, 431 
laceration of the perineum, flap-split- 
ting operation for, 343 
rupture of the recto-vaginal septum, 
258 

cause of, 259 

immediate operation for, 
260 
after-treatment of, 262 
preparations for, 261 
intermediate operation 

for, 263 
secondary operation for, 

263 
symptoms of, 259 

after-treatment of, 266 
treatment of, 260 
Complications met during operation for 
removal of fibroid tumors of the ute- 
rus, 428 
Cone of tissue removed by Sims's amputa- 
tion, 239 
Congenital absence of ovaries, 551 

of the vagina as a cause of ster- 
ility, 126 
epispadias, 135 
hermaphrodism, 132 
hypertrophy of the clitoris, 135 
hypospadias, 135 



Congenital malformation of the bladder, 

622 
Congestion of the ovary, 553 
diagnosis of, 554 
termination of, 554 
treatment of, 554 
Congestive dysmenorrhea, 111 
diagnosis of, 116 
symptoms of, 114 
treatment of, 119 
Conical cervix, 280 
Corpus luteum, 547 

calcification of, 566 
cyst of, 561 
Cup pessary, 328 

Curettage in carcinoma of the vagina, 358 
of the carcinomatous cervix, 379 

after-treatment of, 684 
of the uterus, 214, 219, 222, 242, 283, 
285, 330, 332, 389, 424, 486 
after-treatment of, 233, 683 
for diagnosis, 384, 409 
for membranous dysmenorrhea, 122 
in acute pelvic inflammation, 227 
in sarcoma, 364 
instruments for, 224 
Curette, blunt, 225 
dull, 52 

exploratorv, 52 
sharp, 52, 213 
wire, 52 
Cyst, dermoid, 410 

diagnosis of, 592 
follicular, of the cervix, 237 
multilocular, of ovary, 564 
of broad ligament, 559 

absence of pedicle in, 604 
adhesion in, 602 
of corpus luteum, 561 
of hydatid of Morgagni, 560 
of the labium majus, 182 
of the ovary, 161, 410 

adhesions of, 575, 592 
areolar, 563 

atheromatous changes in, 566 
axial rotation of, 576 
calcification of, 566 
clamp method of removal, 603 
complicated by ascites, 578 
by uterine myoma, 588 
course of, 579 
dermoid, 568 
diagnosis of, 474, 581 
from ascites, 586 
from desmoid tumor, 589 
from distended bladder, 590 
from fecal tumor, 589 
from hepatic cyst, 590 
from hydatid cyst, 590 
from mesenteric cysts, 590 
from obesity, 588 
from omental cysts, 590 
from phantom tumor, 587 
from recto-peritoneal cyst, 591 
from renal cysts, 591 
from splenic tumor, 590 



694 



INDEX, 



Cyst of the ovary, diagnosis of, from tym- 
panitis, 589 
from ventral hernia, 588 
etiology of, 572 
exploratory puncture in, 592 
fatty degeneration of, 566 
follicular, 561 
hemorrhage into, 574 
intestinal obstruction from, 579 
intra-peritoneal method of re- 
moval, 603 
large, 562 

diagnosis from hydramnios, 

585 
physical signs of, 583 
ligation of pedicle, 603 
multilocular, diagnosis of, 591 
pedicle of, 571, 592, 602 
physical signs of, 580 
rupture of, 577 
suppuration of, 574 

symptoms of, 575 
symptoms of, 572 
unilocular, 563 
of vagina, 199 

diagnosis of, 200 
treatment of, 200 
of vulva, 181 

treatment of, 182 
papillary adhesions, 602 
parovarian, 162, 570 

absence of pedicle in, 604 
adhesions in, 602 
diagnosis of, 474 
tubo-ovarian, 561 
Cystic degeneration of the cervix, 236, 
238 
of the ovary, 101 
tumors, diagnosis from pyosalpingitis, 
480 
of the clitoris, 182 
vaginitis, treatment of, 199 
Cystitis, 629 

diagnosis of, 633 
diphtheritic, 630 

prognosis of, 634 
pathology of, 630 
prognosis of, 634 
symptoms of, 631 
treatment of, 634 
Cystocele, 254, 322, 323 

spurious, 240 
Cystomata of the ovary, 395 
Cystoscope, use of, 644 
Cystotomy, 646 

vaginal, 651 
Czerny's method for exstrophv of the blad- 
der, 625 

DAVID'S apparatus for sterilizing cat- 
gut, m 
Decidua expelled from the uterus in ectopic 
gestation, 533 
from ectopic gestation differentiated 
from decidua from intra-uterine 
pregnancy, 535 



Decidua from ectopic gestation differenti- 
ated from membrane of membranous 
dysmenorrhea, 535 
in situ in ectopic gestation, 534 
menstrualis, 93, 112 
reflexa, 96 
vera, 93, 96 
Defectus uteri, 137 

Degenerations of the uterus causing steril- 
ity, 125 
Deposits upon the cervix, 370 
Dermoid cyst, 410 

of ovary, 568 

diagnosis of, 592 
with long red hair, 567 
Deschamp's needles, 421, 423, 426, 435 
Desmoid tumor, 589 

Development of the external genital or- 
gans, 130 
Diagnosis of pelvic tumors, 30 ' 

of retroflexion with the sound, 297 
Diagram of the structures in the broad 

ligament, 558 
Diagrammatic representation of interstitial 
tubal pregnancy, 526 
section of tubal pregnancy, 522 
Didelphic uterus, 141 
Diffuse sarcoma of the uterus, 360 

V symptoms of, 361 

Digital examination in the lateral position, 
31 
per rectum, 25 
per vaginam, 23 
Dilatation of the cervix, 122, 283-286, 408 
by bougies, 121 
by graduated sound, 224 
by incision, 121 
by tents, 47, 121 
gradual, 50 
in sterility, 128 
rapid, 48, 120, 223 
of the genital tract for examination, 46 
of the urethra, 51, 615, 621, 637 
Dilator, Ellenger's, 49 

Goodell's, 49, 120, 223, 637 
Hank's uterine, 48 
Hegar's 621, 650 
Nott's, 48, 49 
Sims's vaginal, 187 
Thomas's, 349 
Diphtheria of the vulva, 172 
Diphtheritic cystitis, 630 
prognosis of, 634 
Direction of the ureters, 25 
Displacements of the uterus, 125 
Distension of the abdomen by ovarian tu- 
mor, 582 
Distortions of the uterus, 278 
Division of the cervix, 128 
Dorsal position, 21, 23, 24, 42, 222, 273, 296, 
389, 413, 636, 643 
examination in, with vaginal re- 
tractors, 45 
Double bladder, 622 

uterus and double vagina, 190 
Douche, vaginal, 242, 488 



INDEX. 



695 



Douche, boracic-acid, for bladder, 651 
Drain, gauze, 69, 611, 672 
Mikulicz, 68, 672 
roll-gauze, 69 
Drainage after removal of ovarian cyst, 605 
of pelvic abscess from vagina, 498 
of the peritoneum, 157 
of uterus with iodoform gauze, 214, 219 
with stem pessaries, 214 
Drainage-tube, glass, 68, 69, 517, 605, 611, 
661 
care of, 70, 670 
removal of, 606 
syringe for cleansing, 70 
time for removal of, 671 
Dressings, 67 

for the abdominal incision, 80, 606, 673 
sterilization of, 541 
Drink, administration of, after coeliotomy, 

662. 
Dropsy of Graafian follicle, 397 
Dudley's operation, 312 
Dull curette, 52 
Duplex uterus, 141 

Dysmenorrhea, 110, 212, 213, 243, 248, 284- 
287, 573 
in anteflexion, 281, 282 
congestive. 111 

diagnosis of, 116 
symptoms of, 114 
treatment of, 119 
description of, 110 
intermenstrual, 110, 115 
mechanical, 112 

diagnosis of 116 
symptoms of, 114 
treatment of, 120 
membranous, 93, 112 
curettement for, 122 
symptoms of, 115 
treatment for, 122 
neuralgia. 111, 114 
diagnosis of, 116 
symptoms of, 113 
treatment of, 117 
obstructive, diagnosis of, 116 
symptoms of, 114 
treatment of, 120 
oophorectomy for, 121 
ovarian, 112 

symptoms of, 115 
treatment of, 121 
pathology of. 111 
prognosis of, 116 
symptoms of, 113 
treatment of, 117 
varieties of. 111 
Dyspareunia, 280 
Dysuria, 324 

ECHINOCOCCUS cysts, properties of 
fluid from, 593 
ficraseur, 374 

Koeberle's, 432 
Ectopic gestation, 327, 518 

changes in the ovum, 528 



Ectopic gestation, diagnosis of, 532 

diagnosis of, from fibro-myoma, 

537 
diagnosis subsequent to rupture, 

536 
etiology of, 520 

extra-peritoneal rupture of, 542 
hemorrhage in, 522, 524 
history of, 518 

intra-peritoneal rupture of, treat- 
ment of, 540 
pathology of, 520 
physical signs of, 530 

at time of rupture, 530 
prior to rupture, 532 
ruptured, diagnosis from ruptured 

pyosalpinx, 537 
symptoms of, 529 
treatment of, 538 
varieties of, 518 
menstruation 94 
Ectropion of the cervix, 240 
Eczema of the vulva, 171 
Electrical treatment of amenorrhea, 103 
of ectopic gestation, 539 
of endometritis, 233 
of fibroids, 412 

adhesions from, 428 
of ovarian cyst, 594 
of pelvic inflammation, 458 
Elephantiasis of the labia, 180 

as a cause of sterility, 126 
of the vulva, 180 
diagnosis of, 180 
treatment of, 186 
Elevator, uterine, 35 
EUingers dilator, 49 
Elliott's uterine elevator, 35 
Elm tent, 47 

Elongation of the cervix, 280 
Emmenagogues, 103 

Emmet's buttonhole operation for prolapse 
of urethra, 622 
method of cystotomy, 646 
modification of Sims's anterior elytror- 

rhaphy, 330 
operation for anterior colporrhaphy, 
332, 335, 338 
for artificial urethral fistula, 275 
for colpo-perineorrhaphy, 330 
for perineorrhaphy, 332 
for relaxed vaginal outlet, 255 
for trachelorrhaphy, 239, 331 
uterine applicator, 40 
elevator, 35 
Emphysematous vaginitis, 196 
Empyema, cocci from, 218 
Enchondroma of vulva, 184 
Encysted tubercular peritonitis, 161 
Endocervicitis, glandular, 236 
gonorrheal, 235 
septic, 235 
symptoms of, 236 
treatment of, 238 
Endometritis, 207, 307, 464 
acute, 101 



696 



INDEX. 



Endometritis, atrophic, 208, 212, 213, 232 
chronic hypertrophic, 320 
electrical treatment of, 233 
fungoid, 208, 211, 213 
glandular, 209 
gonorrheal, 220 

pathology of, 220 
symptoms of, 219, 221 
treatment of, 22] 
hypertrophic, 210 

glandular, with adenomatous de- 
generation, 208 
treatment of, 213 
interstitial, 212 
polypoid, 213 
septic, acute, 216 

pathology of, 216 
chronic, pathology of, 217 
septic, symptoms of, 217 

treatment of, 219 
simple, 207 

symptoms of, 210 
treatment of, 213 
treatment of hemorrhages in, 213 
with chloride of zinc, 214 
Endometrium, anatomy of, 202 

application of carbolic acid to the, 285 
of iodine to the, 215, 226, 233, 242, 
284, 301 
benign hypertrophies of, 363 
during menstruation, 206 
fibre of the, 202 
fifty -three days after application of a 

caustic, 231 
method of reproduction of, 230 
physiology of, 204 
polypoid degeneration of, 381 
puerperal, 217 
senile, 207 

thirteen days after curettage, 232 
thirty-one days after curettage, 232 
three months after curettage, 230 
Enlarged blood-vessels in intra-ligamentary 
fibroids, 426 
in multinodular subserous fibroid 
of the uterus, 405 
Enucleation, vaginal, of fibroid tumors of 

uterus, 413 
Epispadias, congenital, 135 
Epithelioma, cauliflower, of the cervix, 365 
nodular, of the cervix, 365 
of the cervical mucous membrane, 365 
of the cervix, 364 
of the vagina, 356 
of the vulva, 351 
etiology of, 352 
treatment of, 353 
papillary, of the cervix, 365 
parenchymatous, of the cervix, 365 
superficial, of the cervix, 366 
ulcerative, of the cervix, 366 
Ergot, treatment of fibroid tumors of the 

uterus by, 411 
Erosions of the cervix, 238, 290 

of the vagina, phosphatic concretion in, 
273 



Erosions, papillary, of the cervix, 237 
Erysipelas of the vulva, 172 
Escape of fetus in peritoneal cavity in tu- 
bal pregnancy, 522 
Ether, administration of, 598 
Eversion of the rectum, 25, 26 
Examination and treatment at the oflice, 
arrangement for, 21 
at the patient's home, 19, 580 
at the physician's office, 19 
bimanual, 28 
by the uterine sound, 32 
digital, per rectum, 25 
dilatation of the genital tract for, 46 
instrumental, 32 
in the lateral position, bimanual, 31 

digital, 31 
methods of, 23 
ocular, 23 

of the vaginal entrance, 32 
of the female pelvic organs, 17 
per vaginam, digital, 23 
position of patient for, 21 
preparations for, 18 
rectal, 46, 410 
under anesthesia, 46 
with the speculum, 37 
Exanthemata of the vulya, 170 
Exploratory curette, 52 
needle and syringe, 53 
puncture in ovarian cyst, 592 
Exstrophy of the bladder, 623 

Thiersch's operation for, 624 
treatment of, 624 
External genitals, malignant diseases of, 

351 
Extirpation of the cervix, total, 376 
of the coccyx, 185 
of the uterus, total, 376, 420 
in fibroids, 430 

preparation of patient for, 424 
Extra-peritoneal method of supra-vaginal 

hysterectomy, 416 
Extra-uterine pregnancy, 327, 410, 482, 518 
cause of, 452 
diagnosis of, 474, 479 
Extroversion of the bladder, 623 

FALLOPIAN tube, abnormality of, 142 
absence of, 142 
adherent to ovary, 454 
• adhesions of, 506 
anatomy of, 548 
catheterization of, 498 
changes in, at puberty, 550 
colic of the. 111 
human, section of, 550 
in sterility, 124 
malformation of, 551 
method of ligation of, 507 
of Macaque monkey, 548 
of Panolian deer, 549 
palpation of, 29 
stricture of, 501 
tuberculosis of, 151 
diagnosis of, 153 



INDEX. 



697 



Fallopian tube, tuberculosis of, pathology 

of, 151 

prognosis of, 153 

symptoms of, 153 

treatment of, 153 

Fatal hemorrhage in removal of ovarian 

cyst, 608 
Fatty abdominal wall simulating ovarian 
cyst, 589 
degeneration of cvst of ovary, 566 
Fecal fistula, 162, 163,' 267, 275, 613 
after coeliotomy, 679 
tumor resembling ovarian cyst, 589 
Fecundation, artificial, 128 
apparatus for, 129 
Female generative organs, anomalies of, 
130 
examination of, 17 
Fergusson's cylindrical speculum, 43 
Fibre of the endometrium, 202 
Fibrinous peritonitis, 457 
Fibro-cystic tumors of the uterus, 411 
Fibroid of the labium majus, 181 
of the ovary calcified, 569 
of the uterus, 85, 400 
calcification of, 403 
cause of death in, 407 
complication met during opera- 
tion, 428 
diagnosis of, 407 

general consideration of treat- 
ment, 429 
hemorrhage in, 406 
interstitial, 402, 403 
intra-ligamentous, 409, 425 
Martin's operation for, 416 
nodular, 414 

non-operative treatment of, 411 
csdematous submucous, 408 
pain in, 405 
pediculated, 403 
pressure symptoms in, 406 
removal by morcellation, 413, 415 

per vaginam, 431 
salpingo-oophorectomy for, 435 
submucous, 401 
subperitoneal pediculated, 402 
subserous, 402 
surgical treatment of, 413 
symptoms of, 405 
treatment of, by electricity, 412 

by ergot, 411 
vaginal enucleation of, 413 
of vagina, 200 
of the vulva, 181 
polyp of the uterus, 346 
tuberculosis of the peritoneum, 157 
diagnosis of, 158 
prognosis of, 158 
symptoms of, 157 
treatment of, 158 
Fibro-myoma, 537 

accidents occurring during operation 

for, 434 
cause of death after cceliotomy for, 431 
interstitial, diagnosis of, 408 i 



Fibro-myoma, interstitial, paralysis after 
coeliotomy for, 433 
of ovary, 569 
of the uterus, 400 

secondary hemorrhage after coeliot- 
omy for, 431 
sepsis after coeliotomy for, 432 
shock after operations for, 433 
submucous, diagnosis of, 407 
subserous, diagnosis of, 409 
Fibro-papillary hypertrophy of hymen, 

186 
Fibro-sarcoma of the uterus, 359 

symptoms of, 361 
Figure-of-eight ligature of Fallopian tube, 

508 
Fissure of the cervix uteri, 245 
Fistula, abdominal, 516 

fecal, 162, 163, 267, 275, 613 

after coeliotomy, 679 
genital, 267 
intervisceral, 159 
persistent, closure of, 270 
rectal, 159 

recto-vaginal, 276, 339, 684 
recto-vulval, 276 

suppurating, after coeliotomy, 678 
tubercular, of the vagina, 147 
umbilical, 159 
ureteral, 267 

diagnosis of, 268 
sutures in, 269 
treatment of, 268 
uretero-vaginal, 269 
urethral, 275 

artificial, 275 
urinary, 267 

vesical, various forms of, 267 
vesico-uterine, 269 

treatment of, 270 
vesico-utero-vaginal, 271, 272 
vesico- vaginal, 272, 620, 637, 684 

treatment of, 273 
viscero-abdominal, 159 
Flap-splitting method, application of, 342 
for complete laceration of the peri- 
neum, 343 
for incomplete laceration of the 

perineum, 343 
for perineorrhaphy, 330, 342 
Flatulence after coeliotomy, QQ^ 

cause of, 669 
Flexions of the uterus as a cause of steril- 
ity, 125 
Fluid, ascitic, properties of, 593 

from echinococcus cyst, properties of, 

593 
from Graafian follicle, properties of, 593 
from ovarian cyst, properties of, 593 
Follicular cysts of the cervix, 237 
of ovary, 561 
vaginitis, 196 
vulvitis, 168 
Food, administration of, after coeliotomy, 

662 
Forcible dilatation of the cervix, 120 



698 



INDEX. 



Fountain syringe for irrigation, 73 
Frozen section of girl aged thirteen, 299 

Waldeyer's, of the female pelvis, 
300 
Fungus endometritis, 208, 211 

treatment of, 213 

GANGEENE of the vulva, 172 
Gauze-bag drain, 68 
Gauze drain, 69, 611, 672 

dressing the abdominal wound with, 80 
iodoform, drainage of uterus with, 214 

preparation of, 223 
packing of the uterus, 215, 233, 241 
pads used in place of sponges, 596 
sterilization of, 68 
General state of the patient's health in ster- 
ility, 126 
Generative organs, anomalies of, 130 
Genital fistula, 267 

organs, complete absence of, 131 
external, development of, 130 

malformation of, 130 
internal, absence of, 131 
tuberculosis, 144 
Gestation, ectopic, diagnosis of, 532 
from fibro-myoma, 537 
subsequent to rupture, 536 
etiology of, 520 
extra-peritoneal rupture, 542 
hemorrhage in, 522, 524 
history of, 518 
intra-peritoneal rupture, treatment 

of, 540 
pathology of, 520 
physical signs of, 530 

at time of rupture, 530 
prior to rupture, 532 
ruptured, diagnosis from ruptured 

pyosalpinx, 537 
symptoms of, 529 
treatment of, 538 
varieties of, 518 
Gland, vulvo-vaginal, abscess of, treatment 
of, 170 
distension of, 178 
Glandular endocervicitis, 236 
endometritis, 209 
hypertrophy of the cervix, 240 
polypi of the cervix, 240 
uterine polyp, 211 
Glass drainage-tube, 68, 69, 605, 611, 661 
care of, 70, 670 
removal of, 606 
syringe for cleansing, 70 
time for removal of, 671 
Glass-jar irrigator, 74 
Glycerin tampons, 493 
Gonococci, 221 
Gonorrhea, 475, 486, 556 

as a cause of pelvic inflammation, 441 
Gonorrheal endocervicitis, 235 
endometritis, 220 

pathology of, 220 
symptoms of, 219, 221 
treatment of, 221 



Gonorrheal infection, 484 

of the urethra, 616 

treatment of, 616 
vaginitis, 194 
vulvitis, 174 
GoodelFs dilator, 49, 120, 223, 637 

speculum, 40, 42 
Graafian follicles, 545 

apoplexy of, 554 

dropsy of, 397 

freshly-ruptured. 547 

properties of fluid from, 593 
Gradual dilatation of the cervix, 50 
Granular vaginitis, 195 
Gravid Fallopian tube at tenth week, 521 
Gynecological cabinet, 20 

HAGEDOEN needle, 339 
Hands, method of antisepticizing, 56 
method of cleansing, 62 
Hank's uterine dilator, 48 
Hegar's dilators, 621, 650 

method of examination, 582 
operation for colpo-perineorrhaphy, 
330, 338 
for rectocele, 331 
for removal of the adnexa, 430 
Hematidrosis, 94 
Hematocele, pelvic, 530, 537 
etiology of, 531 
physical signs, 531 
Hematoma of the vulva, 176 
ovarian, 531 
pelvic, 530, 537 

changes in, 532 
physical signs, 531 
suppuration of, 542 
Hematometra, 94, 240, 585 
Hematosalpinx, 452, 465 
diagnosis of, 475 
physical signs of, 471 
prognosis of, 484 
Hematuria, 632, 643, 648, 649 
Hemorrhage after coeliotomy, 674 

fatal, in removal of ovarian cyst, 608 

in endometritis, treatment of, 213 

in pregnancy, 108 

into ovarian cyst, 574 

secondary, after coeliotomy for fibromy- 

omata, 431 
transfusion of sterilized salt solution 

after, 432 
uterine, 105, 106 

use of tampon in, 109 
Hepatic cysts resembling ovarian cysts, 590 
Hermaphrodism, bilateral, 132 
congenital, 132 
lateral, 133 

pseudo, proper, 133, 134 
true, 132 
unilateral, 132 
Hernia labialis inguinalis, 178 

of the ovary through the inguinal ca- 
nal, 552 
pudendal, 178 

posterior, 178 



INDEX. 



699 



Hernia, pudendal, treatment of, 178 
vaginalis labialis, 178 
ventral, 613, 680 

diagnosis from ovarian cyst, 588 
sutures in place for repair of, 681 
Herpes of the vulva, 170 
Higbee's speculum, 41, 42, 43, 46 
High amputation of the cervix, 334, 376 
after-treatment of, 377 
by the galvano-cautery, 378 
by the Paquelin cautery, 379 
Horizontal section of abdomen, 544 
Hottentot's apron, 135, 164 
Hydatid cyst resembling ovarian cyst, 590 
of Morgagni, 551 
cyst of, 560 
Hydramnios, 585 

Hydrocele of the labium majus, 177 
Hydrometra, 585 
Hydronephrosis, 320 
Hydrosalpinx, 450, 464 
diagnosis of, 474, 475 
physical signs of, 471 
Hymen, abnormalities of, 135 
atresia of, 135, 188 
hypertrophy of, as a cause of sterility, 

126 
imperforate, 121, 187 
diagnosis of, 190 
Hyperesthesia, vulvo-vaginal, 185 > 

treatment of, 185 
Hyperinvolution of the uterus, 101, 125, 
243 
diagnosis of, 244 
treatment of, 128, 244 
Hypertrophic endometritis, 210 
chronic, 320 

glandular, with adenomatous de- 
generation, 208 
treatment of, 213 
metritis, chronic, 320 
Hypertrophy of anteflexed uterus, 281 
of the bladder-wall, 648 
of the cervix, 240 
glandular, 240 
supravaginal, 333 

symptoms of, 334 
treatment of, 334 
of the clitoris, 165 

congenital, 135 
of the hymen as a cause of sterility, 

126 
of the nymphae, 164 
of the vaginal walls, 189 
Hypospadias, 615 

congenital, 135 
Hysterectomy, 363 
abdominal, 392 
complete, 430, 431 
in ectopic gestation, 543 
supra-vaginal, 349 

extra-peritoneal method, 416 

intra-abdominal method, 419 

through lateral coccygeal incisions, 

392 
through perineal incision, 392 



Hysterectomy through the sacrum, 393 
vaginal, 150, 332, 345, 350, 385, 415 
after-treatment of, 392, 685 
clamp operation, 387 

objection to, 387 
dangers of, 388 
ligation of ureter in, 686 
ligature operation, 389 

objection to, 388 
Hystero-myomectomy, 77 
Hysterorrhaphy, 307, 309, 332, 345, 553 
objections to, 316 
performance of, 313 
removal of the stitches in, 316 
sutures in position in, 314 
Hysterotome, 128 

ICHTHYOL, application of, to the endo- 
metrium, 215 
to the vaginal mucous membrane, 
301 
use of, 558 

vaginal tampons of, 242, 494 
Immediate abdominal operations, prepara- 
tions for, 76 
Imperforate hymen, 121, 187 

diagnosis of, 190 
Incipient cancer of the uterus, 209 
Incision, bilateral, of the cervix, 240 
of the cervix, 213, 408 
short, in abdominal wall, 77 
Incompatibility as a cause of sterility, 126 
Incomplete laceration of the perineum, 
flap-splitting operation for, 343 
operations, 610 

rupture of the recto-vaginal septum, 
old, 253 
area of denudation in, 

256 
introduction of sutures in, 

257 
symptoms of, 255 
treatment of, 255 
recent, 252 

suturing of, 253 
Incontinence of urine following dilatation 

of the urethra, 616 
Indianapolis gynecological chair, 20 
Infantile uterus, 138 

Infection following plastic work upon the 
cervix, 219 
gonorrheal, 484 
septic puerperal, 484 
Inflammation and abscess of the vulvo- 
vaginal glands, 169 
Inflammatory changes in cervical mucous 
membrane, 235 
diseases of the uterus, 202 
Infravaginal elongation of the cervix, 334 
Injuries to the vagina as a cause of sterility, 
126 
of the vulva, 175 
Instrument case, 59, 64 

table, 58 
Instruments, care of, 63 

sterilization of, 64, 222, 541 



700 



INDEX. 



Interlocking ligature, 604 
Intermenstrual dysmenorrhea, 110, 115 
Interstitial endometritis, 212 

fibroid tumor of the uterus, 402, 403 
fibro-myoma, diagnosis of, 408 
ovaritis, 465 

diagnosis of, 475 
pregnancy, 519, 525 
salpingitis, 153, 465 
chronic, 502 
diagnosis of, 475 
lutervisceral fistula, 159 
Intestinal complications in removal of 
ovarian cyst, 612 
obstruction, 434 

from ovarian cyst, 579 
paralysis after coeliotomy for fibro- 
myoma, 433 
Intestines, adhesions of, 505 

lacerations of coats of, in removal of 

ovarian cyst, 612 
wounds of, 434 

care of bowels after, 664 
in removal of ovarian cyst, 609 
Intra-abdominal method of supravaginal 

hysterectomy, 419 
Intra-ligamentous fibroids, 409, 425 
Intra-peritoneal abscess, 455, 461 
physical signs of, 473 
method of removal of ovarian cyst, 
603 
Intra-uterine fibroid polyp, 399 
palpation, 407 

Vulliet's method, 407 
stem pessary, 104, 121, 128 
syringe, 39 
Introduction of the hand into the rectum, 
27 
of the uterine sound, 33 

curves to facilitate, 34 
Inversion of the bladder, 652 
diagnosis of, 652 
symptoms of, 652 
treatment of, 653 
of the uterus, 328, 345 

cause of death in, 347 
diagnosis of, 347 
prognosis of, 348 
Thomas's operation for, 348, 349 
treatment of, 348 
Involution of the uterus, abnormalities of, 

125, 226, 233, 242, 284, 301 
Iodine, application of, to the endometrium, 
215 
to the vaginal vault, 494 
Iodoform gauze, drainage of uterus with, 
214 
packing of the uterus with, 283, 

407, 408, 414 
preparation of, 223 
sterilization of, 606 
lodoformized gauze, preparation of, 68 

oil, injection of, in tuberculosis of blad- 
der, 641 
Irregular menstruation, 81 
Irrigating tube, Baldy's, 74 



Irrigation, fountain syringe for, 73 
glass jar for, 74 
of bladder, 636 

of peritoneal cavity, 510, 542, 605 
of the uterus after dilatation, 225 
Irritable bladder, 114, 625 
diagnosis of 628 
symptoms of, 625, 627 
treatment of, 628 

JACKSON'S perineal retractor, 46 
Jenks's spiral uterine sound, 33 

KELLY'S leg-holder, 71 
pad, 77, 222 
ureteral catheter, 657 
sound, 657 
Knee-chest position, 22, 199, 293, 296, 329 
reposition of the retroflexed uterus, 
295 
Knife for denudation in the operation for 

laceration of the cervix, 249 
Knot, Staffordshire, 508 

Tait's, 508 
Koeberle's ecraseur, 432 
Kraske's operation for hysterectomy, 393 
severance of the ureter in, 393 
wound of the rectum in, 393 
Krug's frame for Trendelenberg's position, 
22,60 

LABIA, adhesions of, 165 
treatment of, 166 
elephantiasis of, 180 
majora, 164 

absence of, 135 
multiplication of, 135 
minora, hypertrophy of, 164 
Labial abscess, 170 
Labium, adipose tumor of, 183 
fibroid of, 181 
majus, cysts of, 182 
hydrocele of, 177 
Laceration of the cervix uteri, 245 
bilateral, 246 

immediate operation for, 246 
incision in the angles of, 249 
knife for denudation in the opera- 
tion for, 249 
method of denudation in the oper- 
ation for, 249 
operation for, 249 
symptoms of, 246 
treatment preparatory to opera- 
tion, 248 
unilateral, 247 
of the perineum, 258 

as a cause of prolapse, 321 

causes of, 259 

immediate operation in, 260 

after-treatment of, 262 
preparation for, 261 
intermediate operation in, 263 
introduction of sutures in, 264 
recognition of the sphincter ani, 
264 



INDEX. 



701 



Laceration of the perineum, secondary oper- 
ation for, 263 
after-treatment of, 266 
symptoms of, 259 
treatment of, 260 
Laminaria tents, 51, 120 
Lateral flexions, 286 

hermaphrodism, 133 
position, examination in, 31 
Le Fort's operation, 330 
Left lateral position, 22, 38, 40, 44, 268, 
299 
appearance of relaxed vaginal 
outlet in, 255 
Leg-holder, Kelly's, 71 

Robb's modification of Kelly's, 71 
Leucorrhea, 84, 114, 156, 211, 212, 218, 248, 
255, 281, 290, 398, 406, 465, 466, 468, 
480, 508 
Ligation of Fallopian tube, method of, 

507 
Ligature, braided silk, 422 
catgut, 339, 388, 391, 603 
figure-of-eight, 508 
interlocking, 604 
materials, 65 
quilting, 509 

rubber, method of fastening, 417 
silk, 388, 422, 507, 603, 653 
Ligatures, application of, in removal of 

fibroid uterus, 421 
Light for operating room, 57 
Lipoma of the vulva, 183 
Lithotrity, 645 

contraindications to, 646 
Long incision in abdominal walls, 79 
Lupus of the vulva, 144-146 
Lymphatics of the uterus, 203 

MALFOEMATION of the bladder, con- 
genital, 622 
of the external genital organs, 130 
Malformations of the vagina as a cause of 

sterility, 126 
Malignant abdominal growths, 161 

adenoma of the uterine mucous mem- 
brane, 382 
diseases of the external genitals, 351 
of the female genitalia, 351 
of the uterus at menopause, 85 
of the vagina, 355 
neoplasms of the urethra, 618 
Malpositions of the uterus, 125, 278 
Management of menstruating women, 97 
Marion Sims's method for replacing the 

uterus, 308 
Marriage, relation of, to amenorrhea, 105 
Martin's operation for fibroids of the uterus, 

416 
Marvin abdominal supporter, 614 
Massage of pelvic organs, 496 
Mechanical antisepsis, 56 
dysmenorrhea, 112 
diagnosis of, 116 
symptoms of, 114 
treatment of, 120 



Medullary sarcoma of the vulva, 353 
Melanoma of vulva, 184 
Membranous dysmenorrhea, 93, 112 
curettement for, 122 
diagnosis of, from ectopic gesta- 
tion, 535 
membranes of, 113 
symptoms of, 115 
treatment for, 122 
Menopause, 83 

after removal of appendages, 512 
artificially induced, in treatment of 

fibroids, 430 
awakening of sexual desire by, 84 
description of, 83 
diagnosis of, 86 

following removal of appendages, 682 
malignant disease of the uterus at, 

85 
pathology of, 86 . 
prognosis of, 87 
symptoms of, 84, 87 
synonyms of, 83 ^ 

treatment of, 87 
uterine hemorrhage at, 85 
vicarious hemorrhages during, ^^ 
Menorrhagia, 89, 90, 220 
and metrorrhagia, 105 
causes of, 105 
frequency of, 105 
pathology of, 107 
prognosis of, 107 
treatment of, 107 

between periods, 108 
Menses, retention of, 94 
Menstrual discharge, coagula in, as proof 
of abortion, 91 
composition of, 90 
quantity of, 90 
source of, 91 
endometrium, 92 
flow, 204 
pad, 97 
Menstruating endometrium, 206 
women, management of, 97 
Menstruatio alba, 91 
Menstruation, 81, 205 

after oophorectomy, 95 

and ovulation, 95 

disturbance of, in pelvic inflammation, 

467 
during pregnancy, 96 
effect of climate upon, 83 
establishment of, 81 
excessive, 573 
irregularity of, 81 
regularity and duration, 81 
suppression of, as a symptom of preg- 
nancy, 584 
synonyms, 81 

time of the cessation of, 85 
vicarious, 94 
Mesentery, cysts of, diagnosis from ovarian 

cyst, 590 
Method of cleansing the abdomen, 77 
glass drainage-tube, 70 



702 



INDEX. 



Method of denudation in operation for 
lacerated cervix, 214 
of enlarging the abdominal incision, 

78 
of examination, 23 
of making application to uterus, 215 
of opening the abdomen, 76 
the peritoneum, 76, 78 
Metritis, 241 
acute, 101 
chronic, 101 

hypertrophic, 320 
Metrorrhagia, 105, 530, 534, 537 
causes of, 105 
frequency of, 105 
pathology of, 107 
prognosis of, 107 
treatment of, 107 
Microcysts of broad ligament, 560 
Mikulicz drain, 68, 672 
Miliary tuberculosis of the peritoneum, 154 
diagnosis of, 156 
prognosis of, 156 
symptoms of, 155 
treatment of, 156 , 
Mole, tubal, 528 
Monsel's solution, use of, 602 
Morcellation of fibroid tumor of uterus, 
413 
removal of fibroid by, 415 
Morgagni, cyst of, 551 

hydatid of, cyst of, 560 
Mucus-patch of the vulva, 174 
Multilocular cysts of ovary, 564 
diagnosis of, 591 
or glandular cystoma, 564 
Multinodular fibroid tumor of uterus, show^- 

ing enlarged blood-vessels, 405 
Multiplication of the labia majora, 135 
Myoma of uterus complicating ovarian 

cyst, 588 
Myomectomy, 416 

NEEDLE, bayonet-pointed, 314 
D^schamp's, 421, 423, 426, 435 
exploratory, 53 
for the performance of Schiicking's 

operation, 306 
Hagedorn, 339 
Nelson's trivalve speculum, 42-44 
Neoplasm of bladder, diagnosis of, 649 
prognosis of, 650 
symptoms of, 648 
treatment of, 650 
of ovary, 559 

of the urethra, malignant, 618 
of the vagina, 199 
Neuralgic dysmenorrhea, 111 
diagnosis of, 116 
symptoms of, 113, 114 
treatment of, 117 
Neuroma of vulva, 184 
Nodular epithelioma of the cervix, 365 
Noma, 172 

Normal mucous membrane of the cervix, 
204 



Normal position of the uterus, 24 

sphincter, 260 
Nott's dilator, 48, 49 

trivalve speculum, 42, 44 
Nurse, duties of, in ovariotomy, 612 
Nymphse, absence of, 135 

hypertrophy of, 164 

sarcoma of, 353 

OBESITY, 588 
Obstructive dysmenorrhea, diagnosis 
of, 116 
symptoms of, 114 
treatment of, 120 
Occlusion, complete, of the vagina, 188 
Ocular examination, 23 
(Edematous submucous fibroid tumor of the 

uterus, 408 
Omentum, adhesions of, 504 
disposal of, 434 
cancerous disease of, 410 
cysts of, diagnosis from ovarian cysts, 

590 
tuberculosis of, 160, 410 
Oophorectomy, 244 

for dysmenorrhea, 110, 121 
menstruation following, 95 
Opening the abdomen, 76 

the peritoneum, 76, 78 
Operating room, 60 
light for, 57 
technique of, 57 
suits, 61 
table, 75 
Operations, boiled water for, 60 
Operator, responsibility of, 61 
Ovarian abscess, 449, 456, 468 
diagnosis of, 478 
prognosis of, 484 
cyst, 161 

course of, 579 
diagnosis of, 474 

from distended bladder, 590 
from fecal tumor, 589 
from hepatic cyst, 590 
from hydatid cyst, 590 
from mesenteric cysts, 590 
from obesity, 588 
from omental cysts, 590 
from renal cysts, 591 
from splenic tumors, 590 
intra-peritoneal method of re- 

' moval, 603 
pedicle of, 571 
disease complicating fibroid of uterus, 

429 
dysmenorrhea, 112 
symptoms of, 115 
treatment of, 121 
hematoma, 531 
neoplasms, 559 
pregnancy, 518 
Ovaries, adhesions of, 506 
in sterility, 123 
palpation of, 29 
Ovariotomy, 396, 594 



INDEX. 



703 



Ovariotomy, emptying the cyst in, 599 
operation of, 598 
preparation of the instruments for, 595 

of the patient for, 595 

of the room for, 595 

of the sponges for, 596 
separation of adhesions in, 690 
sequelae of, 611 
Ovaritis, acute, 555 

course and termination of, 556 

etiology of, 556 

symptoms of, 556 

treatment of, 556 
chronic, 112, 502 

diagnosis of, 557 

etiology of, 556 

symptoms of, 557 

treatment of, 557 
interstitial, 465 

diagnosis of, 475 
Ovary, abnormality of, 143 
absence of, 143 
adenoma of, 565 
adhesion of, 460 
anatomy and physiology of, 544 
areolar cyst of, 563 
atrophy of, 101 
calcified fibroma of, 569 
carcinoma of, 393, 570 

treatment of, 396 
congenital absence of, 551 
congestion of, 553 

diagnosis of, 554 

termination of, 554 

treatment of, 554 
cystic degeneration of, 101 
cyst of, 410 

adhesions of, 575, 592 

atheromatous changes in, 566 

axial rotation of, 576 

calcification of, 566 

clamp method of removal, 603 

complicated by ascites, 578 
by uterine myoma, 588 

diagnosis of, 581 

from ascites, 586 
from desmoid tumor, 589 
from phantom tumor, 587 
from recto-peritoneal cyst, 591 
from tympanitis, 589 

etiology of, 572 

exploratory puncture in, 592 

fatty degeneration of, 566 

hemorrhage into, 574 

intestinal strangulation from, 579 

pedicle of, 592, 602 
ligation of, 603 

physical signs of, 580 

rupture of, 577 

suppuration of, 574 
symptoms of, 575 

symptoms of, 572 

treatment of, 593 
cystomata of, 395 
dermoid cyst of, 568 
fibro-myoma of, 569 



Ovary, follicular cysts of, 561 
hernia of, treatment of, 552 
inguinal hernia of, 552 
large cysts of, 562 

diagnosis of, from hydramnios, 

585 
physical signs of, 583 
malformations of, 551 
multilocular cysts of, 564 
diagnosis of, 591 
papillomatous cystic tumor of, 394 
prolapse of, 552 

diagnosis of, 552 
etiology of, 552 
treatment of, 553 
sarcoma of, 396, 569 
diagnosis of, 397 
treatment of, 397 
tuberculosis of, 152, 153 
tumor of, 410 
solid, 569 
unilocular cyst of, 563 
Ovulation, 95 
Ovum, human, 547 

PACKING of the uterus with gauze, 233, 
407, 408, 414 
Pad, Kelly's, 222 

Pain continuing after removal of appen- 
dages, 513 
in pelvic inflammation, 466, 490 
Palpation, intra-uterine, 407 

by Vulliet's method, 407 
of the coccyx, 26 
of the interior of the bladder, 52 
of the normal Fallopian tube, 29 
of the ovaries, 29 
of the pelvis, bimanual rectal, 30 
of the round ligament, 29 
of the ureter, 24, 29 
of the uterus, bimanual, 28, 224 
bimanual recto-vaginal, 31 
per rectum, 27 
Papillary adenoma of the uterus, 210 
cystomata, 566 
cysts, adhesions in, 602 
epithelioma of the cervix, 365 
erosion of the cervix, 237 
excrescences of vagina, 201 
Papillomatous cystic tumor of the ovum, 
394 
disease of broad ligaments, 395 
Paquelin cauterv, 354, 364, 379, 389, 420, 

509, 602 
Parenchymatous epithelioma of the cervix, 

365 
Parovarian cyst, 162, 570 

absence of pedicle in, 604 
adhesions in, 602 
diagnosis of, 474 
Parovarium, 550 
Passage of the uterine sound in case of 

version or flexion, 44 
Patulous urachus, 623 
Pedicle of ovarian cyst, 571, 592, 602 
ligation of, 603 



704 



INDEX. 



Pedicle of ovarian cyst, torsion of, 576 
Pediculated fibroid tumor of the uterus, 

403 
Pelvic abscesses, 60, 463, 480, 481, 499, 677 
cause of death in, 485 
cceliotomy for, 542 
drainage of, from vagina, 498 
incision of, through vagina, 542 
treatment of, 502, 678 
vaginal opening of, 500, 502 
cellulitis, 437, 611 
hematocele, 530, 537 
etiology of, 531 
physical signs, 531 
hematoma, 530, 537 
changes in, 532 
physical signs of, 531 
suppuration of, 542 
inflammation, 437 

acute, curettage of uterus in, 227 

caused by specific infection, 441 

cause of, 439 

conservative treatment of, 514 

diagnosis of, 473 

menstrual disturbances in, 467 

pain in, 466, 490 

pathological anatomy of, 444 

physical signs of, 470 

prognosis of, 483 

removal of appendages in, 504 

results of, 449 

symptoms of, 463 

treatment of, 485 

by electricity, 458 
prophylactic, 485 
organs, massage of, 496 
peritoneal tuberculosis, 160 
peritonitis, 101, 437 

caused by venereal excess, 441 
fibrinous form, 447 
serous form, 447 
suppurative form, 447 
suppuration, neglected cases of, 516 
Pelvis, frozen section of, 300 

removal of exudate from, 611 
Perforation of the softened uterine body by 

the sound, 34 
Perineal pad, 73 
retractor, 38 

introduction of, 41 
Jackson's, 46 
Perineorrhaphy, administration of food af- 
ter, 684 
after-treatment of, 683 
Emmet's operation for, 33^ 
flap-splitting method, 342 
application of, 342 
Perineum, laceration of, 258 

after-treatment of, 262 

as a cause of prolapse, 321 

causes of, 259 

complete, flap-splitting operation 

for, 343 
immediate operation in, 260 
incomplete, flap-splitting operation 
for, 343 



Perineum, laceration of, intermediate oper- 
ation in, 263 
introduction of sutures in, 264 
preparation for, 261 
recognition of the sphincter ani, 

264 
secondary operation for, 263 

after-treatment of, 266 
symptoms of, 259 
treatment of, 260 
Perioophoritis, 555 
Peritoneal cavity, irrigation of, 510, 605 

method of opening, 504, 598, 609 
Peritoneum, caseous tuberculosis of, 159 
course of, 160 
diagnosis of, 161 
prognosis of, 162 
symptoms of, 160 
treatment of, 162 
drainage of, 157 
fibroid tuberculosis of, 157 
diagnosis of, 158 
prognosis of, 158 
symptoms of, 157 
treatment of, 158 
miliary tuberculosis of, 154 
diagnosis of. 156 
prognosis of, 156 
symptoms of, 155 
treatment of, 156 
opening the, 76, 78 
toilet of, 604 
tuberculosis of, 154 
Peritonitis, 469 

acute, cceliotomy during, 512 
chronic, from ovarian carcinoma, 395 
diagnosis of, 480 
encysted tubercular, 161 
fibrinous, 457 
patholo2:v of, 446 
pelvic, 101, 437 

caused by venereal excess, 441 
fibrinous form, 447 
serous form, 447 
suppurative form, 447 
serous, 457 

suppurative, 447, 449 
Periurethral cancer, 354 
Permanent catheter, 666 
Permanganate-of-potash solution for steril- 
izing the hands, 62, 63 
Persistent fistulae, closure of, 270 

retroposition, cause of, 309 
Pessary, 301, 302, 328 

contraindication to, 302 
cup, 328 

drainage of uterus with, 214 
for complete prolapse, 305 
hollow rubber-ball, 330 
intra-uterine stem, 121, 128 
introduction of, 303 
Smith-Hodge, 302, 494 
soft rubber-ring, 302 
stem, 104, 239, 284, 305 
Thomas and Munde, 553 
use of, 128 



INDEX. 



705 



Phantom tumor, 587 

Phosphatic concretions in erosions of the 

vagina, 273 
Photomicrograph of chorionic villi, 538 
of section of decidua of ectopic gesta- 
tion, 535 
Physiology of the endometrium, 204 
Physometra, 585 
Placental wound, septic infection through, 

448 
Plastic operations, 70 

after-treatment of, 683 
preparation of patient for, 70 
upon the cervix, infection follow- 
ing, 219 
Polyp, fibroid, of the cervix, 398 
of the uterus, 346, 398 
symptoms of, 399 
treatment of, 399 
glandular, of the cervix, 240 

of the uterus, 211 
mucous, from cervical canal, 236 
of the bladder, 648 
urethral, 618 

diagnosis from caruncle, 619 
uterine, 328 
Polypoid cervicitis, 238 

degeneration of the endometrium, 381 
endometritis, 213 
Position, dorsal, 21, 23, 24, 42, 222, 273, 296, 
389, 413, 636, 643 
examination in, with vaginal re- 
tractors, 45 
knee-chest, 22, 199, 293, 296, 329 
left lateral, 22, 38, 40, 1<^'^, 299, 637 
normal, of the uterus, 24 
of patient, for examination, 21 
right lateral, 393 
Sims's, 22, 38, 40, 268, 299, 637 
Trendelenberg's, 22, 60, 313, 332, 392, 

419, 420, 432, 433, 434, 435, 505 
upright, 22 
Pregnancy, ectopic, 318 

erratic hemorrhages in. 108 
extra-uterine, 327. 410,' 482, 518 

diagnosis of, 474, 479 
in uterus unicornis, 138 
ovarian, 518 
tubal, 519 

diagnosis subsequent to rupture, 

536 
escape of fetus in peritoneal cav- 
ity, 522 
period of rupture, 527 
rupture of wall, 521 

with fetal life continuing, 543 
tubo-ovarian, 519 
tubo-uterine, 519, 525 

direction of rupture, 526 
Pregnant Fallopian tube laid open, 527 
Preparation for abdominal operations, 75 
for an examination, 18 
for immediate abdominal operations, 

76 
for ovariotomy, 596 
of iodoform gauze, 223 

45 



Preparation of the instruments for ovari- 
otomy, 595 
of the patient for ovariotomy, 595 

for plastic operation, 70 
of the room for ovariotomy, 595 
of the sponges, 67 
Preparatory cleansing in vaginal operations, 
72 
treatment of abdominal operations, 75 
Probe, silver, for the uterus, 215 
Prolapse of the ovary, 552 
diagnosis of, 552 
etiology of, 552 
treatment of, 553 
of the urethra, 621 
diagnosis of, 621 
symptoms of, 621 
treatment of, 622 
of the uterus, 318 
acute, 332 

as a cause of sterility, 125 
cause of, 320 
complete, formation of, 325 

ulceration in, 321 
diagnosis of, 328 
pathology of, 318 
prognosis of, 328 
symptoms of, 326 
treatment of, 328 
varieties of, 318 
Proliferating cystomata, 562 
Proligerous glandular cyst of ovary, 563 
Prurigo of the vulva, 171 
Pruritus vulvse, 172, 466 
causes of, 172 
diagnosis of, 173 
treatment of, 173 
Pryor's method of closing abdominal wound, 

311 
Pseudo-hermaphrodism proper, 133, 134 
Puberty, 546 
Pudendal hernia, 178 
posterior, 178 
treatment of, 178 
Puerperal endometrium, 217 
septicemia, 441 
septic infection, 484 
Purgatives, administration of, after coeliot- 

omy, 663 
Purulent salpingitis, 502 
vulvitis, 167 

symptoms of, 167 
treatment of, 167 
Pyokolpos, 191 
Pyometra, 191 
Pyonephrosis, 626 
Pyosalpinx, 437, 455, 468 
acute, 461 
diagnosis of, 478 

in a woman over sixty years old, 515 
prognosis of, 484 
tubercular, 152 
with multiple abscess-cavities, 501 

r\UILTING ligature, 509 



706 



INDEX. 



RAPID dilatation of the cervix, 408 
of the uterus, 48 
Eectal examination, 46 
fistulas, 159 

palpation of the pelvis, bimanual, 30 
of the uterus, 27 
Eectocele, 254, 322, 323 
E.ecto-peritoneal cysts, diagnosis from ova- 
rian cysts, 591 
E-ecto-vaginal cloaca, 136 
fistula, 276, 339, 684 
septum, complete rupture of, 258 
causes of, 259 

immediate operation in, 260 
after-treatment of, 262 
preparations for, 261 
intermediate operation in, 263 
secondary operation for, 263 

after-treatment of, 266 
symptoms of, 259 
treatment of, 260 
old incomplete rupture of, 253 

area of denudation in, 

256 
introduction of sutures in, 

257 
symptoms of, 255 
treatment of, 255 
recent incomplete rupture of, 252 

suturing of, 253 
suture of, in Hegar's operation, 
340 
Recto-vulval fistula, 276 
Eectum, eversion of, 25, 26 
examination through, 410 
introduction of hand into, 27 
sinus of, 517 
wounds of, 434 

during removal of ovarian cyst, 

609 
in Kraske's operation, 393 
Reduction in uterine retrodisplacements, 
290 
of the stump in supra-vaginal hyster- 
ectomy, 418 
Relation of the ureters to the cervix, 419 
Relaxation of the vaginal outlet, 253 

appearance of, in Sims's posi- 
tion, 255 
Removal of appendages, changes following, 
516 
in pelvic inflammation, 504 
pain continuing after, 513 
Renal cysts, diagnosis from ovarian cysts, 

591 
Reposition of the adherent retrodisplaced 
uterus, 295 
of the retroflexed uterus, bimanual, 
290, 293 
in fat women, 293 
in knee-chest position, 293 
with the sound, 297 
of the uterus, 30 

with the sound, 36 
Repositor, Aveling's, 350 
Sims-Pryor, 298 



Rest after coeliotomy, 660 
Retractor, Byford's lateral vaginal, 46 
Jackson's perineal, 46 
Simon's, 45, 46 
Retroflexion, acquired, 288 
symptoms of, 289 
bimanual replacement in, 290 
congenital, 287 

treatment of, 288 
reposition of, in fat women, 293 
treatment of, 301 
Retropositions of the uterus, value of the 
various procedures for the relief of, 
317 
persistent, cause of, 309 
Retroversion, acquired, 288 
symptoms of, 289 
congenital, 287 

treatment of, 288 
correction of, by distended rectum, 

128 
treatment of, 301 
with adhesions, 308 
with anteflexion, 280 
treatment of, 283 
without enlargement, treatment of, 302 
Right lateral position, 393 
Robb's modification of Kellv's leg-holder, 

71 
Roll-gauze drain, 69 
Room for operating, 60 

for the administration of anesthesia, 
59,60 
Rosenmiiller, organ of, 550, 560 
Round ligament, palpation of, 29 
shortening of, 307 

by Alexander's operation, 309 
by Dudley's operation, 312 
by Wylie or Baer's operation, 
312 
topographical anatomy of, 310, 311 
Rubber ligature, method of fastening, 417 
Rudimentary uterus, 137 
Rupture of ovarian cyst, 577 

in its removal, 607 
of the recto-vaginal septum, complete, 
258 

causes of, 259 
immediate operation in, 
260 
after - treatment of, 

262 
preparation for, 261 
intermediate operation in, 

263 
secondary operation for, 
263 
after-treatment of, 
266 
symptoms of, 259 
treatment of, 260 
incomplete, old, 253 

area of denudation, 256 
introduction of sutures 

in, 257 
symptoms of, 253 



INDEX. 



707 



Rupture of the recto- vaginal septum, in- 
complete, old, treatment of, 
255 
recent, 252 

suturing of, 253 

SALPINGITIS, adherent, 453 
catarrhal, 449, 457, 465 
diagnosis of, 473 
physical signs of, 471 
symptoms of, 464 
chronic, 453, 461 

interstitial, 453, 502 
interstitial, 465 

diagnosis of, 475 
purulent, 502 
suppurative, 454, 459 
tubercular, 151, 160, 465 
Salpingo-oophorectomy for fibroid, 435 
Salt solution for irrigation of peritoneal 

cavity, 542, 605 
Sarcoma of the ovary, 396, 569 
diagnosis of, 397 
treatment of, 397 
of the urethra, 618 
of the uterus, causes of, 360 
diagnosis of, 362 

from benign hypertrophies, 363 
from carcinoma, 363 
diffuse, 360 

symptoms of, 361 
primary, 359 
prognosis of, 363 
treatment of, 363 
of the vagina, 355 
diagnosis of, 355 
prognosis of, 356 
treatment of, 356 
of the vulva, 353 
Scarification of the cervix uteri, 248, 490 
Schiicking's operation, 306 
• Scirrhous carcinoma of the vulva, 353 
Secondary amenorrhea, 101 

hemorrhage after cceliotomy for fibro- 
myomata, 431 
Section of ovary, 547 
Separation of adhesions, 428 
Sepsis, 434, 675 

after coeliotomy for fibro-myoma, 432 
after gynecological operations, 55 
Septicemia, 470, 478 

puerperal, 441 
Septic endometritis, 235 
acute, 216 

pathology of, 216 
chronic, pathology of, 217 
symptoms of, 217 
treatment of, 219 
infection as a cause of pelvic inflam- 
mation, 441 
from the placental wound, 448 
puerperal, 484 
Senile endometrium, 207 
uterus, 101 

vaginitis, treatment of, 199 
Serous peritonitis, 457 



Serre-noeud for hysterectomy, 417 
Sexual desire awakened by menopause, 84 
Sharp curette, 52, 213 
Shock after cceliotomy, 675 

for fibro-myomata, 433 
treatment of, 675 
Shortening the round ligaments, 307 
Shotted sutures in the operation for lacera- 
tion of the cervix uteri, 251 
gilk ligature, 388, 507 

suture, 65, 250, 257, 265, 269, 272, 274, 
276, 312, 377, 416, 418, 434, 506, 
596, 603, 615, 653, 682 
interrupted, 262, 271 
Silkworm-gut sutures, 250, 253, 257, 262, 
265, 269, 272, 274, 276, 311, 313, 
336, 339, 340, 416, 418, 511, 596, 
605, 614, 653 
sterilization of, 66 
Silver-wire suture, 65, 239 
Simon's method of examination in the dor- 
sal position, 45 
retractors, 45, 46 
speculum, 656 
Simple endometritis, 207 
vaginitis, 194 

vegetations of the vulva, 174 
vulvitis, 166 

treatment of, 166 
Simpson's uterine sound, 32, 33, 215 
Sims-Pryor uterine repositor, 298 
Sims's double-end depressor, 38 

method for replacing the uterus, 308 
operation of amputation of the cervix, 

239 240 
position, 22, 38, 40, 44, 255, 268, 299, 637 
appearance of relaxed vaginal out- 
let in, 255 
speculum, 38, 41. 51, 246, 248, 249, 268, 
273, 295, 656 
introduced, 39 
uterine elevator, 35 

sound, 32, 33 
vaginal dilator, 187 
Sinus of bladder, 517 

of rectum, 517 
Skin of abdomen, sterilization of, 541 
Smith- Hodge pessary, 302, 494 
Soda solution for sterilizing instruments, 

222 
Soft rubber-ring pessary, 302 
Solid tumor of ovary, 569 
Sound, Simpson's, 2i5 
ureteral, Kelly's, 657 
uterine, 32 

caution in using, 327 

curves to facilitate introduction of, 

34 
dangers of, 34 
introduction of, 33 
passage of, in case of version or 
flexion, 44 
into the Fallopian tube, 35. 
perforation of uterus by, 34 
replacement of the uterus with, 36, 
297 



708 



INDEX, 



Sound, uterine, uses of, 34 

Sounding of the bladder, method of, 643 

of the ureters, 656 
Specific infection as a cause of pelvic in- 
flammation, 441 
Speculum, Brewer's 41-43 
examination with, 37 
Fergusson's cylindrical, 43 
Goodell's 40, 42 
Higbee's, 41, 42, 43, 46 
Nelson's tri valve, 42-44 
Nott's trivalve, 42, 44 
Simon's, 656 

Sims's, 38, 41, 46, 51, 246, 248, 249, 268, 
273, 295, 656 
introduced, 39 
Talley's 40, 42, 43 
Taylor's, 41-43 
Sphincter ani, union of, in Hegar's opera- 
tion, 340 
normal, 260 

solution of continuity of, 260 
Spider-web adhesion, 459, 460 
Spleen, tumors of, diagnosis from ovarian 

cyst, 590 
Splitting the cervix, 50 
Sponge tents, 49, 120, 440 

use of, in uterine hemorrhage, 109 
Sponges, cleansing of, after operation, 67 

preparation of, 67 
Spurious cystocele, 240 
Staffordshire knot, 508 
Stem pessaries, 104, 121, 128, 239, 284, 305 

drainage of uterus with, 214 
Stenosis of the cervix, cicatricial, 240 
of the vagina, 189 
diagnosis of, 191 
Sterility, 123, 213, 280, 281, 282, 284, 557 
cause of, 452 
congenital absence of the vagina as a 

cause of, 126 
degenerations of the uterus causing, 125 
dependent upon incompatibility of the 

parties, 126 
diagnosis of, 127 
elephantiasis labiorum as a cause of, 

126 
etiology of, 123 
general state of the patient's health in, 

126 
hvpertrophy of the hymen as a cause 

\of, 126 
injuries to the vagina as a cause of, 126 
in ovarian cysts, 573 
malformations of the vagina as a cause 

of, 126 
operation for, 283 
prognosis of, 127 

prolapse of the uterus as a cause of, 125 
resident in the male, 127 
the Fallopian tubes in, 124 
the ovaries in, 123 
the uterus in, 124 
treatment of, 127 

urethral caruncle as a cause of, 126 
uterine flexions as a cause of, 125 



Sterility, uterine versions as a cause of, 125 

vaginitis as a cause of, 126 
Sterilization by boiling water, 56 
by steam, QQ 
chemical, 56 
of absorbent cotton, 67 
of catgut by boiling in alcohol, 66 

by ether, 66 
of dressings, 541 
of gauze, 68 
of hands, 62 

of instruments, 64, 222, 541 
of iodoform, 606 
of silk, 65 
of silkworm-gut, &Q 
of skin of abdomen, 77, 541 
Sterilized towels, 77 
Sterilizer, Arnold's, 64, 66 
Stitch-abscesses, 611 
Stitches, removal of, after cceliotomy, 673 

after operation for laceration of 
the cervix uteri, 251 
Stoltz's operation for anterior colporrhaphy, 
330, 332, 336 
contraindication to, 337 
Stricture of the Fallopian tube, 501 
of the ureter, 657 
of the urethra, 620 
diagnosis of, 621 
prognosis of, 621 
symptoms of, 620 
treatment of, 621 
Stripping off" the parietal peritoneum in re- 
moval of ovarian cyst, 607 
Structure of calcified fibroma, 570 
Stump after removal of uterine appendages, 
511 
reduction of, in supra- vaginal hyster- 
ectomy, 418 
Subinvolution of the uterus, 125, 241, 248 

symptoms of, 242 
Submucous fibroid of the uterus, 401 
diagnosis of, 407 
oedematous, 408 
Subperitoneal pediculated fibroid tumor of 

the uterus, 402 
Subserous fibroid of the uterus, 402 

diagnosis of, 409 
Superficial epithelioma of the cervix, 366 
Superinvolution of the uterus, 243 
Suppressio mensium, 98 
Suppression of menstruation as a symptom 

of pregnancy, 584 
Suppurating fistula after cceliotomy, 678 
Suppuration of ovarian cyst, 574 
symptoms of, 575 
of the wound after cceliotomy, 674 
pelvic, neglected cases of, 516 
Suppurative peritonitis, 447, 449 

salpingitis, 454, 459 
Supra-pubic amputation of the uterus, 430, 

431 
Supra-vaginal hypertrophy of the cervix, 
333 
symptoms of, 334 
treatment of, 334 



INDEX, 



709 



Supra-vaginal hysterectomy, 349 

extra-peritoneal method, 416 
intra-abdominal method, 419 
Suture, catgut, 310, 313, 332, 336, 339, 340, 
377, 389, 418, 506, 596, 609, 614, 
682 
sterilization of, 66 
in position for the repair of ventral 
hernia, 681 
in hysterorrhaphy, 314 
in operation for laceration of the 
cervix uteri, 250 
introduction of, in flap-splitting opera- 
tion, 344 
materials, ^b 
of recent incomplete rupture of the 

recto-vaginal septum, 253 
of thin fold of peritoneum and fibrous 
tissue after detachment of a firm ad- 
hesion from intestine, 428 
removal of, in combined operations, 

685 
silk, 65, 250, 257, 265, 269, 272, 274, 276, 
312, 377, 416, 418, 434, 506, 596, 
603, 615, 653, 682 
interrupted, 262, 271 
sterilization of, 65 
silkworm-gut, 250, 253, 257, 262, 265, 
269, 272, 274, 276, 311, 313, 336, 
339, 340, 344, 416, 418, 511, 596, 
605, 614, 653 
sterilization of, 66 
silver-wire, 65, 239 
tendon, 65 
tobacco-pouch, 337 
Syndroma menstrualis, 93 
Syphilitic affections of the vulva, 174 

skin eruptions of the vulva, 174 
Syringe, Braun's intra-uterine, 226 
bulb, 226 
exploratory, 53 

for cleansing drainage-tube, 70 
for removal of cervical secretion, 218 
fountain, for irrigation, 73 
intra-uterine, 39 

TABLE for instruments, 58 
for operation, 75 
the Allison gynecological, 19 
Tait's knot, 508 

operation of removal of the adnexa, 
430 
Talley's speculum, 40, 42, 43 
Tampons, 199 

of the uterus, 226 

for hemorrhage, 109 
instruments for, 226 
with iodoform gauze, 227 
of vagina, 215, 233, 296, 299, 301, 309, 
311 
for hemorrhage, 109 
for prolapsed uterus, 329 
introduction of, 40, 44 
of glycerin, 493 
of ichthyol, 242, 294 
of iodoform gauze, 253, 316, 377 



Taxis in inversion of the uterus, 348 
Taylor's speculum, 41-43 
Technique of abdominal operations, 75 
of gynecological operations, 54 
of the operating room, 54 
Tenaculum, 39 

knife-bladed, for scarification of the 
cervix uteri, 248 
Tendon suture, 65 
Tenotomy for coccygodinia, 184 
Tent, elm, 47 

laminaria, 51, 120 
sponge, 49, 120, 440 
tupelo, 50, 51, 120 
use of, in sterility, 128 
Thermic antisepsis, 56 
Thiersch's operation for exstrophy of the 
bladder, 624 "- 

solution, 424, 433 
Thomas and Munde pessary, 553 
Thomas's dilator, 349 

operation for inversion of the uterus, 

348, 349 
whalebone uterine sound, 33 
Tobacco-pouch suture, 337 
Toilet of peritoneum, 604 
Torsion of the pedicle of cyst of ovary, 

576 
Total extirpation of the cervix, 376 
of the uterus, 376, 431 
abdominal, 420 
in fibroids, 430 

preparation of patient for, 
424 
Trachelorrhaphy, 332 

after-treatment of, 683 
Emmet's operation for, 239, 331 
Transfusion of sterilized salt solution after 

hemorrhage, 432 
Transverse section of pelvis with ectopic 

gestation, 524 
Trendelenberg's method for exstrophy of 
the bladder, 625 
position, 22, 313. 332, 392, 419, 420, 
432-435, 505 
Krug's frame for, 60 
Triple interlocking ligature, 604 
True hemaphrodism, 132 
Tubal abortion, 525 

disease complicating fibroids of uterus, 

429 
mole, 528 
pregnancy, 519 

diagnosis subsequent to rupture, 

536 
escape of fetus in peritoneal cavity, 

522 
period of rupture, 527 
rupture of wall, 521 
rupture of, with fetal life continu- 
ing, 543 
rupture in a case of ectopic gestation, 
540 
Tubercle bacilli, recognition of, in urine, 

639 
Tubercular fistula of the vagina, 147 



710 



INDEX. 



Tubercular, peritonitis, encysted, 161 
pyosalpinx, 152 
salpingitis, 151, 160, 465 
Tuberculosis of the bladder, 638 
diagnosis of, 639 
pathology of, 638 
prognosis of, 640 
treatment of, 640 
of the cervix uteri, 147 
diagnosis of, 149 
treatment of, 149 
of the Fallopian tubes, 151 
diagnosis of, 153 
pathology of, 151 
prognosis of, 153 
symptoms of, 153 
treatment of, 153 
of the omentum, 160 
of the ovary, 152, 153 
of the pelvic peritoneum, 160 
of the peritoneum, 154 
caseous, 159 

course of, 160 
diagnosis of, 161 
prognosis of, 162 
symptoms of, 160 
treatment of, 162 
fibroid, 157 

diagnosis of, 158 
prognosis of, 158 
symptoms of, 157 
treatment of, 158 
miliary, 154 

diagnosis of, 156 
prognosis of, 156 
symptoms of, 155 
treatment of, 156 
of the uterus, 149 
diagnosis of, 150 
symptoms of, 150 
treatment of, 150 
of the vagina, 146 

treatment of, 147 
of the vulva, 144 

diagnosis of, 145 
treatment of, 145 
Tubo-ovarian abscess, 457 
cyst, 561 
pregnancy, 519 
Tubo-uterine pregnancy, 519, 525 
direction of rupture, 526 
Tumor, adipose, of labium, 183 
of clitoris, 183 
cystic, 182 
of the vulva, 180 
Tupelo tents, 50, 51, 120 
Tympanitis resembling ovarian cyst, 589 

ULCERATIVE epithelioma of the cer- 
vix, 366 
Umbilical fistulse, 159 
Unicornate uterus, 138 
Unilateral hermaphrodism, 132 

laceration of the cervix uteri, 247 
Unilocular cyst of ovary, 563 
Upright position, 22 



Urachus, patulous, 623 
Uremia after coeliotomy, 667 
Ureter, calculus of, 658 
cancer of, 658 
catheterization of, 656 
course of, marked on abdomen, 656 
direction of, 25 
diseases of, 653 

diagnosis of, 654 
ligation of, in vaginal hysterectomy, 

686 
normal, palpation of, 654 
palpation of, 24, 29 

pelvic portion of, viewed from above, 
655 
viewed from below, 654 
relation to the cervix, 419 
severance of, in Kraske's operation, 393 
sounding of, 656 
stricture of, 657 
wound of, 435 

during operation for ovarian cyst, 
609 
Ureteral catheter, 634, 639 
Kellv's, 657 
fistula, 267 

diagnosis of, 268 
sutures in, 269 
treatment of, 268 
sound, Kelly's, 657 
Ureteritis, 659 
Uretero-vaginal fistula, 269 
Urethra, abscess of, 617 
atresia of, 615 

treatment of, 615 
carcinoma of, 354, 618 
caruncle of, 619 
dilatation of, 51, 615, 621, 637 
gonorrheal infection of, 616 

treatment of, 616 
malignant neoplasms of, 618 
prolapse of, 621 

diagnosis of, 621 
symptoms of, 621 
treatment of, 622 
sarcoma of, 618 
stricture of, 620 

diagnosis of, 621 
prognosis of, 621 
symptoms of, 620 
treatment of, 621 
Urethral caruncle, 617 

as a cause of sterility, 126 
medullary sarcoma of, 353 
diverticulum, 619 
fistula, 275 

artificial, 275 
polyp, 618 

diagnosis of, from caruncle, 619 
Urethrocele, 619 

diagnosis of, 620 
etiology of, 619 
symptoms of, 619 
treatment of, 620 
Urinary fistula, 267 
Uro-recto-vaginal cloaca, 136 



INDEX, 



711 



Uterine applicator, 215, 225 
colic, 114 

curettement, after-treatment of, 683 
dressing-forceps, Bozeman's, 40 

By ford's, 39 
elevator, 35 
' flexions, as a cause of sterility, 125 
hemorrhage, 105, 106 

at menopause, 85 

tampon in, 109 

use of sponge tents in, 109 
polypus, 328 
probe, silver, 215 
repositor, 295 

method of using, 295 
retrodisplacements, reduction in, 290 
sound, caution in the use of, 327 
versions as a cause of sterility, 125 
Uterus, abnormality in position of, 142 

of involution of the, 125 
absence of, 137 
atrophy of, 320 
benign adenoma of, 209 
bicornate unicervical, 140 
bicornis, 139 

pregnancy in, 584 

retention of menses in, 94 
bimanual palpation of, 28, 224 

recto-vaginal palpation of, 31 
bipartitus, 138 
carcinoma of, 381 

diagnosis of, 384 

symptoms of, 382 

treatment of, 385 
complete prolapse of, formation of, 325 

ulceration in, 321 
curettage of, 214, 219, 222, 242, 283, 
285, 330, 332, 389, 424, 486 

for diagnosis, 384, 409 

in acute pelvic inflammation, 227 

in sarcoma, 364 

instruments for, 224 
degenerations of, causing sterility, 125 
didelphys, 141 
diffuse papillary adenoma of, 210 

sarcoma of, 360 

symptoms of, 361 
dilatation of, 122 
discharge of tubal contents through, 

465 
displacements of, 125 
distortions of, 278 

drainage of, with iodoform gauze, 214, 
219 

with stem pessaries, 214 
duplex, 141 

fibro-cystic tumor of, 411 
fibroid of, 400 

calcification of, 403 

cause of death in, 407 

complications met during opera- 
tion, 428 

diagnosis of, 407 

general consideration of treat- 
ment, 429 

hemorrhage in, 406 



Uterus, fibroid of, Martin's operation for, 
416 

nodular, 414 

non-operative treatment of, 411 

pain in, 405 

pressure-symptoms in, 406 

removal by morcellation, 413, 415 
per vaginam, 431 

salpingo-oophorectomy for, 435 

surgical treatment of, 413 

symptoms of, 405 

treatment of, by electricity, 412 
by ergot, 411 

vaginal enucleation of, 413 
fibroid polyp of, 346, 396 
symptoms of, 399 
treatment of, 399 
fibro-myoma of, 400 
fibro-sarcoma of, 359 

S3''mptoms of, 361 
gauze packing of, 215 
glandular polyp of, 211 
hyperinvolution of, 101, 125, 243 

diagnosis of, 244 

treatment of, 128, 244 
incipient carcinoma of, 209 
infantile, 138 

inflammatory diseases of, 202 
in sterility, 124 
interstitial fibroid of, 402, 403 
inversion of, 328, 345 

cause of death in, 347 

diagnosis of, 347 

prognosis of, 348 

Thomas's operation for, 348, 349 

treatment of, 348 
irrigation of, after dilatation, 225 
lymphatics of the, 203 
malpositions of, 125, 278 
method of making applications to, 215 
mucous membrane of, during men- 
struation, 92 
myoma of, complicating ovarian cyst, 

588 
normal mucous membrane of, 92 
(edematous, submucous fibroid of, 408 
packing of, 233, 241 

with iodoform gauze, 283, 407, 408, 
414 
palpation of, per rectum, 27 
pediculated fibroid of, 403 
primary sarcoma of, 359 
prolapse of, 318 

acute, 332 

as a cause of sterility, 125 

cause of, 320 

diagnosis of, 328 

pathology of, 318 

prognosis of, 328 

symptoms of, 326 

treatment of, 328 

varieties of, 318 
replacement of, 30 
rudimentarius, 137 
sarcoma of, cause of, 360 

diagnosis of, 362 



712 



INDEX, 



Uterus, sarcoma of, differential diagnosis 
from benign hypertro- 
phies, 363 
from carcinoma, 363 

prognosis of, 363 

treatment of, 363 
senile, 101 
septus, 140 
subinvolution of, 125, 241, 248 

treatment of, 242 
submucous fibroid of, 401 
subperitoneal pediculated fibroid of, 

402 
subserous fibroid of, 402 
supra-in volution of, 243 
supra-pubic amputation of, 430, 431 
tamponade of, 226 

instruments for, 226 

with iodoform gauze, 227 
total extirpation of, 376, 431 

in fibroids, 430 
tuberculosis of, 149 

diagnosis of, 150 

symptoms of, 150 

treatment of, 150 
unicornis, 138 

pregnancy in 138 

VAGINA, absence of, 136 
atresia of, 136, 187 

causes of, 187 

course of, 189 

prognosis of, 192 

symptoms of, 190 

treatment of, 192 

varieties of, 189 
carcinoma of, 356 

diagnosis of, 357 

etiology of, 356 

operative treatment of, 358 

palliative treatment of, 358 

symptoms of, 357 
complete occlusion of, 188 
congenital absence of, as a cause of 

sterility, 126 
cysts of, diagnosis of, 200 

treatment of, 200 
epithelioma of, 356 
fibroid tumors of, 200 
hot douches of, 242 
injuries to, as a cause of sterility, 126 
iodoform-gauze tampon of, 316 
malformation of, as a cause of sterility, 

J 26 
neoplasms of, 199 
papillary excrescences of, 201 
phosphatic concretions in erosions of, 

273 
sarcoma of, 355 

diagnosis of, 355 

prognosis of, 356 

treatment of, 356 
stenosis of, 189 

diagnosis of, 191 
tampon of, 215, 233, 296, 299, 301, 309, 
311 



Vagina, tampon of, for prolapsed uterus, 329 
with ichthyol, 242 
with iodoform gauze, 253 
tubercular fistula of, 147 
tuberculosis of, 146 
treatment of, 147 
Vaginal cysts, 199 

amputation of the inverted uterus, 350 
cystotomy, 651 
douches, 488 

enucleation of fibroid of the uterus, 413 
hysterectomy, 150, 332, 345, 350, 385, 
415 
after-treatment of, 392, 685 
clamp operation, 387 

objection to, 387 
dangers of, 388 
ligation of ureter in, 686 
ligature operation, 389 

objection to, 388 
operations, preparatory cleansing in, 72 
outlet, relaxation of, 253 

appearance of, in Sims's posi- 
tion, 255 
virginal, 252 
palpation of the ureters, 24 
tampons, introduction of, 40, 44 
of glycerin, 493 
of ichthyol, 494 
of iodoform gauze, 377 
Vaginismus, 186, 280, 28] 

treatment of, 186 
Vaginitis, 193 
adhesive, 195 
as a cause of sterility, 126 
cystic, treatment of, 199 
diagnosis of, 197 
emphysematous, 196 
etiology of, 193 
follicular, 196 
gonorrheal, 194 
granular, 195 
pathology of, 194 
prognosis of, 197 
senile, treatment of, 199 
simple, 194 
symptoms of, 196 
treatment of, 197 
varieties of, 194 
vesicular, 196 

treatment of, 199 
Valleix's painful points, 114, 116 
Value of the various procedures for relief 

of retropositions of the uterus, 317 
Varicose veins of the vulva, 177 
Vascular papillomatous fibroma of the 

bladder, 647 
Vegetations, simple, of the vulva, 174 
Venereal warts of vulva, 175 
Ventral hernia, 613 

diagnosis from ovarian cyst, 588 
sutures in place for repair of, 681 
Versions of the uterus as a cause of sterility, 

125 
Vertical mesial section of prolapsus uteri,. 
319 



INDEX. 



713 



Vesical calculus, 641 

diagnosis of, 643 
etiology of, '642 
prognosis of, 644 
symptoms of, 642 
treatment of, 644 
fistula, various forms of, 267 
Vesico-uterine fistula, 269 
treatment of, 270 
Vesico-utero-vaginal fistula, 271, 272 
Vesico-vaginal fistula, 272, 620, 637, 684 

treatment of,' 273 
Vesicular vaginitis, 196 

treatment of, 199 
Vestibule, veins of, 175 
Vicarious hemorrhages during menopause, 
85 
menstruation, 94 
Virginal vaginal outlet, 252 
Viscero-abdominal fistulse, 159 
Volvulus, 612 

Vomiting after coeliotomy, 661 
Vulliet's method of intra-uterine palpation, 

407 
Vulva, abscess of, 178 
angioma of, 184 
carcinoma of, symptoms of, 354 

treatment of, 354 
chancre of, 174 
chancroid of, 175 
cysts of, 181 

treatment of, 182 
diphtheria of, 172 
eczema of, 171 
elephantiasis of, 180 
diagnosis of, 180 
treatment of, 181 
enchondroma of, 184 
epithelioma of, 351 
etiology of, 352 
treatment of, 353 
erysipelas of, 172 
exanthemata of, 170 
fibroids of, 181 
gangrene of, 172 
hematoma of, 176 
herpes of, 170 
injuries of, 175 
lipoma of, 183 
lupus of, 144, 145, 146 
medullary sarcoma of, 353 
melanoma of, 184 
.mucus-patch of, 174 
neuroma of, 184 
prurigo of, 171 
pruritus of, 172, 466 



Vulva, pruritus of, causes of, 172 

diagnosis of, 173 

treatment of, 173 
sarcoma of, 353 
scirrhous carcinoma of, 353 
simple vegetations of, 174 
syphilitic skin eruptions of, 174 
tuberculosis of, 144 

diagnosis of, 145 

treatment of, 145 
tumors of, 180 
varicose veins of, 177 
venereal warts of, 175 
Vulvitis, follicular, 168 

causes of, 168 

symptoms of, 169 

treatment of, 169 
gonorrheal, 174 
purulent, 167 

symptoms of, 167 

treatment of, 167 
simple, 166 

treatment of, 166 
Vulvo-vaginal gland, abscess of, 170 

distention of, 178 

inflammation and abscess of, 169 

treatment in inflammation of, 169 
hyperesthesia, 185 

treatment of, 185 

WALDEYER'S frozen section of the 
female pelvis, 300 
"Wedge-shaped amputation of th^e cervix, 

238 
Wire curette, 52 
Wound of bladder, 434 
care after, 666 
during removal of ovarian cyst, 

610 
during vaginal hysterectomy, 687 
of the colon, 434 
of the intestines, 434 

care of bowels after, 664 
during removal of ovarian cyst, 
609 
of the rectum, 434 

during removal of ovarian cyst, 
609 
of the ureter, 435 

during removal of ovarian cyst, 
609 
Wylie's or Baer's operation, 312 

■yENOMENIA, 94 



(•V) 



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Provost and Professor of the Theory and Practice of Medicine and of Clinical Medicine, 
University of Pennsylvania. 

Scarlatina, Measles, Kotheln, Variola, Varioloid, Vaccinia, Varicella, Mumps, Whoop- 
ing-cough, Anthrax, Hydrophobia, Trichinosis, Actinomycosis, Glanders, and 
Tetanus. 

JAMES T. WHITTAKER, M.D., 

Professor of the Theory and Practice of Medicine and of Clinical Medicine, Medical 
College of Ohio, Cincinnati. 

Tuberculosis, Scrofula, Syphilis, Diphtheria, Erysipelas, Malaria, Cholera, and 

Yellow Fever. 

W. GILMAN THOMPSON, M.D., 

Professor of Physiology, New York University Medical College. 

Nervous, Muscular, and Mental Diseases (Including Opium Habit, etc.). 

HORATIO C. WOOD, M.D., 

Professor of Materia Medica, Pharmacy, and General Therapeutics, and Clinical 
Professor of Nervous Diseases, University of Pennsylvania. And 

WILLIAM OSLER, M.D., 

Professor of Practice of Medicine, Johns Hopkins University, Baltimore, Md. 

4 



VOLU3IE II. (Ready Shortly) will contain: 

Urine (Chemistry and Microscopy), 

JAMES W. HOLLAND, M.D., 

Professor of Medical Chemistry and Toxicology, Jefferson Medical College, Phila- 
delphia. 

• Kidneys and Lungs. 

l^KANCIS DELAFIELD, M.D., 

Professor of Pathology and Practice of Medicine, College of Physicians and Surgeons, 
New York City. 

Air^passages (Larynx and Bronchi) and Pleura. 

JAMES C. WILSON, M.D, 

Professor of Practice of Medicine and of Clinical Medicine, Jefferson Medical College, 
Philadelphia, 

Pharynx, (Esophagus, Stomach, and Intestines (Including Intestinal Parasites). 

WILLIAM PEPPER, M.D., 

Provost and Professor of the Theory and Practice of Medicine and of Clinical Medicine, 
University of Pennsylvania. 

Peritoneum, Liver, and Pancreas. 
REGINALD H. FITZ, M.D., 

Hersey Professor of the Theory and Practice of Physic, Harvard Medical School. 

Diathetic Diseases (Bheumatism, Rheumatoid Arthritis, (xout, Lithaemia, and Diabetes). 

HENRY M. LYMAN, M.D., 

Professor of Principles and Practice of Medicine, Rush Medical College, Chicago, 111. 

Heart, Aorta, Arteries, and Veins. 

E. G. JANEWAY, M.D., 

Professor of Principles and Practice of Medicine, Belle vue Hospital Medical College, 
New York City. 

Blood and Spleen. 

WILLIAM OSLER, M.D., 

Professor of Practice of Medicine, Johns Hopkins University, Baltimore, Md. 

Inflammation, Embolism, Thrombosis, Fever, and Bacteriology. 

W. H. WELCH, M.D., 

Professor of Pathology, Johns Hopkins University, Baltimore, Md. 



The articles are not written as though addressed to students in lectures, but are exhaust- 
ive descriptions of diseases with the newest facts as regards Causation, Symptomatology, 
Diagnosis, Prognosis, and Treatment, and will include a large number of approved 
Formulae. The recent advances made in the study of the bacterial origin of various 
diseases are fully described, as well as the bearing of the knowledge so gained upon 
prevention and cure. The subjects of Bacteriology as a whole and of immunity are 
fully considered in a separate section. 

Methods of diagnosis are given the most minute and careful attention, thus enabUng 

the reader to learn the very latest methods of investigation without consulting works 

specially devoted to the subject. 

5 



IN ACTIVE PEEPARATION. 



For Sale by Subscription only. 



M AMERICAN TEXT-BOOK 



OF THE 



DISEASES OF CHILDREN. 

INCLUDING 

Special Chapters on Essential Surgical Subjects ; Diseases of the 

Eye, Ear, Nose, and Throat ; Diseases of the Skin ; and on the 

Diet, Hygiene , and General Management of Children. 

BY AMERICAN TEACHERS. 

EDITED BY 

LOUIS STAEE, M.D., 

ASSISTED BY 

THOMPSON S. WESTCOTT, M.D. 

Forming one handsome royal 8vo. volume of over 1100 pages, profusely 
illustrated with wood-cuts, half tone and colored plates. 

Price, Cloth, $7.00 ; Sheep, $8.00 ; Half Russia, $9.00. 

An American Text-book of the Diseases of Children will be issued as a 
handsome imperial octavo volume of about 1000 pages, uniform with an 
American Text-book of Surgery, containing numerous wood-cuts, half-tone 
plates, and colored illustrations. The plan contemplates a series of original 
articles written b}'' some sixty well-known psediatrists, representing collec- 
tively the teachings of the most prominent medical schools and colleges of 
America. The work is intended to be a practical book, suitable for constant 
and handy reference by the practitioner and the advanced student. 

One decided innovation is the large number of authors, nearly ever}?- article 
being contributed by a specialist in the line on which he writes. This, while 

6 



entailing considerable labor upon the editors, has resulted in the publication 
of a work thoroughly new and abreast of the times. 

Especial attention has been given to the consideration of the latest accepted 
teaching upon the etiology, symptoms, pathology; diagnosis, and treatment of 
the disorders of children, with the introduction of many special formulae and 
therapeutic procedures. 

Special chapters embrace at unusual length the diseases of the Eye, Ear, 
Nose and Throat, and the Skin ; while the introductory chapters cover fully the 
important subjects of Diet, Hygiene, Exercise, Bathing, and the Chemistry of 
Food. Tracheotomy, Intubation, Circumcision, and such minor surgical pro- 
cedures coming within the province of the medical practitioner, are carefully 
considered. 

LIST OF CONTRIBUTORS. 



Dr. S. S. Adams, Washington. 

John Ashhurst, Jr., Philadelphia. 
A. D. Blackador, Montreal, Can. 
Dillon Brown, New York. 
Edward M. Buckingham, Boston. 
Charles W. Burr, Philadelphia. 
W. E. Casselberry, Chicago. 
Henry D wight Cbapin, New York. 
W. S. Christopher, Chicago. 
Archibald Church, Chicago. 
Floyd M. Crandall, New York. 
Andrew F. Currier, New York. 
Roland G. Curtin, Philadelphia. 
J. M. Da Costa, Philadelphia. 
I. N. Danforth, Chicago. 
Edward P. Davis, Philadelphia. 
John B. Deaver, Philadelphia. 
G. E. de Schweinitz, Philadelphia. 
John Doming, New York. 
Charles Warrington Earle, Chicago. 
Wm. A. Edwards, San Diego, Cal. 
F. Forcbheimer, Cincinnati. 
J. Henry Fruitnight, New York 
Landon Carter Gray, New York. 
J. P. Crozer Griffith, Philadelphia. 
W. A. Hardaway, St. Louis. 
M. P. Hatfield, Chicago. 
Barton Cooke Hirst, Philadelphia. 
H. Illoway, Cincinnati. 
Henry Jackson, Boston. 
Charles G. Jennings, Detroit. 
Henry Koplik, New York. 



Dr. Thomas S. Latimer, Baltimore. 
Albert P. Leeds, Hoboken, N. J. 
J. Hendrie Lloyd, Philadelphia. 
George Roe Lockwood, New York. 
Henry M. Lyman, Chicago. 
Francis T. Miles, Baltimore. 
Charles K. Mills, Philadelphia. 
John H. Musser, Philadelphia. 
Thomas R. Neilson, Philadelphia. 
W. P. Nortbrup, New York. 
William Osier, Baltimore. 
Frederick A. Packard, Philadelphia. 
William Pepper, Philadelphia. 
Frederick Peterson, New York. 
W. T. Plant, Syracuse. 
William M. Powell, Atlantic City. 
B. Alexander Randall, Philadelphia. 
Edward O. Shakespeare, Philada. 
F. C. Shattuck, Boston. 
J. Lewis Smith, New York. 
Louis Starr, Philadelphia. 
M. Allen Starr, New York. 
J. Madison Taylor, Philadelphia. 
Charles W. Townsend, Boston. 
James Tyson, Philadelphia. 
W. S. Thayer, Baltimore. [Mich. 
Victor C. Vaughan, Ann Arbor, 
Thompson S. Westcott, Philadelphia. 
Henry R. Wharton, Philadelphia. 
J. William White, Philadelphia. 
J. C. Wilson, Philadelphia. 



FOR !SA1<£ BY iSUBiiCBIPTIOJV. 

FOR FURTHER PARTICULARS, ADDRESS THE PUBLISHER. 



AN AMERICAN TEXT-BOOK OF GYNECOLOGY, 

MEDICAL AND SURGICAL 

FOR THE USE OF 

STUDENTS AND PRACTITIONERS, 

BY 

HENRY T. BYFORD, M. D., JOHN M. BALDY, M. D., 

EDWIN CRAGIN, M. D., J. H. ETHERIDGE, M. D., 

WILLIAM GOODELL, M. D., HOWARD A. KELLY, M. D., 

FLORIAN KRUG, M. D., E. E. MONTGOMERY, M. D., 
WILLIAM R. PRYOR, M. D., GEORGE M. TUTTLE, M. D. 

EDITED BY 

J. M.BALDY, M.D. 



Forming a handsome royal 8vo volume, with 360 illustrations 
in text and 37 colored and half-tone plates. 

Price, Cloth, $6.00; Sheep, $7.00; Half Russia, $8.00. 



In this volume all anatomical descriptions excepting what is essential to ? 
clear understanding of the text have been omitted, illustrations being largely 
depended upon to elucidate this point. It will be found thoroughly practical in 
its teachings, and is intended, as its title implies, to be a working text-book for 
physicians and students. A clear line of treatment has been laid down in every 
case, and, although no attempt has been made to discuss mooted points, still 
the most important of these have been noted and explained ; and the opera- 
tions recommended are fully illustrated, so that the reader may have a picture 
of the procedure described in the text under his eye and cannot fail to grasp 
the idea. 

All extraneous matter and discussions have been carefully excluded, and the 
attempt made to allow nothing unnecessary to cumber the text. 

The subject matter has been brought fully up to date at every point, and 
the work is as nearly as possible the combined opinion of the ten specialists 
who figure as the authors. 

The work is well illustrated throughout with wood-cuts, half-tone and colored 
plates, mostly original, and selected from the authors' private collections. 



For Sale by Subscription only. 
THIRD AND REVISED EDITION -Now Ready. 

Medical Diagnosis. 

BY 

DR. OSWALD YIERORDT, 

Professor of Medicine at the University of Heidelberg ; formerly Privat Docent at University of 
Leipzig ; Professor of Medicine and Director of the Medical Polyclinic at the Univ. of Jena. 

Translated, with additions, from the Second Enlarged German Edition, 

with the Author's Permission. 

BY 

FKANCIS H. STUART, A.M., M.D., 

Member of the Medical Society of the County of Kings, N. Y. ; Fellow of the New York Academy of 
Medicine ; Member of the British Medical Association, etc. 

In one handsome royal octavo volume of 700 pages, 
178 fine wood-cuts in text, many of which are in colors. 

I^vice, Cloth, $4,00 net; Sheep, $5.00 net; Half Russia, $6,50 net. 

This valuable work is now published in German, English, Russian, and Italian. 

In this work, as in no other hitherto published, are given full and accurate explanations 
of the phenomena observed at the bedside. It is distinctly a clinical work, by a master 
teacher, characterized bj thoroughness, fulness, and accuracy. It is a mine of information 

UPON THE points THAT ARE SO OFTEN PASSED OVER WITHOUT EXPLANATION. Especial attention 

has been given to the germ theory as a factor in the origin of disease. 

The issue oi-' a third edition within two years indicates the favor with which it has 

BEEN RECEIVED BY THE PROFESSION. 



PROFESSIONAL OPINIONS. 

" One of the most valuable and useful works in medical literature." 

(Signed) ALEXANDER J. C. SKENE, M.D., 

Dean of the Long Island College Hospital, and Professor of the 

Medical and Surgical Diseases of Women. 



" Indispensable to both ' students and practitioners.' " 

(Signed) F. MINOT, M.D., 

Hersey Professor of Theory and Practice of Medicine, Harvard University. 

" It is very well arranged and very complete, and contains valuable features 
not usually found in the ordinary books." 

(Signed) J. H. MUSSER, M.D., 

Assistant Professor Clinical Medicine, University of Pennsylvania. 

"One of the most valuable works now before the profession, both for study and 

(Signed) N. S. DAVIS, M.D., 

Professor of Principles and Practice of Medicine and Clinical Medicine, Chicago Medical College, 

" A treasury of practical information which will be found of daily use to every 
busy practitioner who will consult it." 

(Signed) C. A. LINDSLEY, M.D., 

Professor of Theory and Practice of Medicine, Yale University, New Haven, Conn. 

a 



For Sale by Subscription only. 

NOW READY. 



DISEASES OF THE EYE. 

A Hand-Book of Ophthalmic Practice. 



G. E. DE SCHWEINITZ, M.D., 

Professor of Diseases of the Eye, Philadelphia Polyclinic ; Professor of Clinical Ophthalmology, Jefferson 

Medical College, Philadelpliia ; Ophthalmic Surgeon to Children's Hospital and to the Philadelphia 

Hospital ; Ophthalmologist to the Orthopaedic Hospital and Infirmary for Nervous Diseases; 

late Lecturer on Medical Ophthalmoscopy, University of Pa., etc. 

FORMING A HANDSOME ROYAL 8vo. VOLUME OF MORE THAN 600 PAGES. 

Over 200 fine wood-cuts, many of which are original, and two chromo- 

lithographic plates. 

JPviee, Cloth, $d,00 net; Sheep, $5.00 net; Half JRussia, $6,50 net. 



PROFESSIONAL OPINIONS. 

" A work that will meet the requirements not only of the specialist, but of the 
general practitioner in a rare degree. I am satisfied that unusual success awaits it." 

(Signed) WILLIAM PEPPER, M.D., 

Provost and Professor of Theory and Practice of Medicine and Clinical Medicine 

in the University of Pennsylvania. 



" Contains in concise and reliable form the accepted views of Ophthalmic Science.'* 

(Signed) WILLIAM THOMSON, M.D., 

Professor of Ophthalmology, Jefferson Medical College, Philadelphia, Pa. 



** One of the best hand-books now extant on the subject." 

(Signed) J. O. STILLSON, M.D., 

Professor of Eye and Ear, Central College Physicians and Surgeons, Indianapolis, Ind. 



" Vastly superior to any book on the subject with which I am familiar." 

(Signed) FRANCIS HART STUART, M.D., 

Brooklyn, N. Y. 

" Contains in the most attractive and easily understood form just the sort of 
knowledge which is necessary to the intelligent practice of general medicine and 
surgery." 

(Signed) J. WILLIAM WHITE, M-D., 

Professor of Clinical Surgery in the University of Pennsylvania. 



" A very reliable guide to the study of eye diseases, presenting the latest facts 
and newest ideas." 

(Signed) SWAN M. BURNETT, M.D., 

Professor of Ophthalmology and Otology, Medical Department Univ. of Georgetown, Washington, Z>. G, 



10 



Second Revised Edition, For Sale by Subscription only. 

A NEW PRONOUNCING 

DICTIONARY OF MEDICINE. 



WITH 



Phonetic Pronunciation, Accentuation, Etymology, etc. 

BY 

JOHN M. KEATING, M.D., LL.D., 

Fellow of the College of Physicians of Philadelphia ; Vice-President of the American Psediatric 

Society ; Ex-President of the Association of Life Insurance Medical Directors ; 

Editor "Cyclopaedia of the Diseases of Children," Etc. ; 

AND 

HENRY HAMILTON, 

Author of a "A new Translation of Virgil's ^neid into English Rhyme ;'* 
Co- Author of " Saunders' Medical Lexicon," Etc. 

WITH THE COLLABORATION OF 

J. CHALMERS Da COSTA, M.D., and FREDERICK A. PACKARD, M.D. 

WITH AN APPENDIX 

CONTAINING IMPORTANT TABLES OF BACILLI, MICROCOCCI, LEUCOMAINES, 

PTOMAINES; DRUGS AKD MATERIALS USED IN ANTISEPTIC SURGERY; 

POISONS AND THEIR ANTIDOTES ; WEIGHTS AND MEASURES ; 

THERMOMETRIC SCALES ; NEW OFFICINAL AND 

UNOFFICINAL DRUGS, ETC. ETC. 

Forming One very Attractive Volume of over 800 Pages. 
Price, Oloth, $5.00 net; Sheep, $6.00 net; Half Eussia, $6.50 net. 

With Denison's Patent Index for Ready Reference. 



"I am much pleased with Keating's Dictionary, and shall take pleasure in recommending it to my 

(Signed) HENRY M. LYMAN, M.D., 

Professor of Principles and Practice of Medicine, Rztsh Medical College, Chicago, III. 

"I am convinced that it will be a very valuable adjunct to my study table, convenient in size and 
sufficiently full for ordinary use." 

(Signed) C. A. LINDSLEY, M.D., 

Professor of Theory and Practice of Medicine, Medical Dept. Yale JJniversity , 

Secretary Connecticut State Hoard of Health, New Haven, Connecticut. 

" I will point out to my classes the many good features of this book as compared with others, which 
will, I am sure, make it very popular with students." 

(Signed) JOHN CRONYN, M.D., LL.D., 

Professor of Principles and Practice of Medicine and Clinical Medicine; 
President of the Faculty, Medical Dept. Niagara University, Buffalo, N. Y. 

" My examination and use of it have given me a very favorable opinion of its merit, and it will give 
me pleasure to recommend its use to my class." 

(Signed) J. W. H. LOVEJOY, M.D., 

Professor of Theory and Practice of Medicine, and President of the Faculty, 

Medical Dept. Georgetown University , Washington, D. C. 
11 



Second Edition^ for Sale by Subscription. 



AUTOBIOGRAPHY 



OF 



SAMUEL D. GROSS, M.D., 

D. C. L. OXON., LL..D. CANTAB., EDIN., JEFF. COLL., UNIV. PA., EMERITUS PROFESSOR 
OP SURGERY IN THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA. 

WITH REMINISCENCES OF 

HIS TIMES AND CONTEMPORARIES. 

Edited by his Sons, Samuel W. Gross, M.D., LL.D., late Professor of Principles 

of Surgery and of Clinical Surgery in the Jefferson Medical College, 

and A. Haller Gross, A.M., of the Philadelphia Bar. 

Preceded by a Memoir of Dr. Gross by the late Austin Flint, M.D., LL.D. 

In two liandsome volumes, each containiDg' over 400 pages, 
demy 8vo., extra cloth, g^ilt tops, with fine Frontispiece 

engraved on steel. 

Price . . . $5.00 net. 

THIS Autobiography, which was continued by the late eminent 
Surgeon until within three months before his death, con- 
tains a full and accurate history of his early struggles, trials, 
and subsequent successes, told in a singularly interesting and 
charming manner, and embraces short and graphic pen portraits 
of many of the most distinguished men — surgeons, physicians, 
divines, lawyers, statesmen, scientists, etc. etc. — with whom he was 
brought in contact in this country and in Europe ; the whole 
forming a retrospect of more than three-quarters of a century. 

12 



SA.TJN"DEB8' 

POCKET MEDICAL FORMULARY. 

By WILLIAM M. POWELL, M.D., 

Attending Physician to the Mercer House for Invalid Women, at Atlantic City. 

CONTAINING 

1750 Formulae, selected from several hundreds of the best known authorities. 

Forming a handsome and convenient Pocket Companion of nearly 300 printed pages, 

with blank leaves for additions. 

WITH AN APPENDIX 

Containing Posological Table ; Formulae and Doses for Hypodermic Medication ; Poisons and 

their Antidotes ; Diameters of the Female Pelvis and Foetal Head ; Obstetrical Table ; 

Diet List for various diseases ; Materials and Drugs used in Antiseptic Surgery ; 

Treatment of Asphyxia from Drowning ; Surgical Remembrancer ; Tables of 

Incompatibles ; Eruptive Fevers ; Weights and Measures, etc. 

Third Edition, Kevised and greatly Enlarged. 
Handsomely bound in Morocco, witli side index, wallet, and flap. 

PHcCf $1.75 net. 

" This little book, that can be conveniently carried in the pocket, contains an immense amount of 
material. It is very useful, and as the name of the author of each prescription is given, is unusually 
reliable." — New York Medical Record. 

THIRD EDITION. 



HOW TO EXAMIIE EOE LIFE IISTJEAICE. 

By JOHN M. KEATING, M.D., 

Fellow of the College of Physicians and Surgeons of Philadelphia ; Vice-President of the American 
Paediatric Society ; Ex-President of the Association of Life Insurance Medical Directors. 

Royal 8vo., 211 pages, with two large Phototype Illustrations, and a 

Plate prepared by Dr. McClellan from special Dissections ; 

also, numerous Cuts to elucidate the text. 

Price, in Cloth, $2.00, 

PART I. has been carefully prepared from the best works on Physical Diagnosis, and is 
a short and succinct accouDt of the methods used to make examinations ; a descrip- 
tion of the normal condition, and of the earliest evidences of disease. 

PART II. contains the Instructions of twenty-four Life Insurance Companies to their 
medical examiners. 

PRESS NOTICES. 

" This is by far the most useful Dook which has yet appeared on insurance examination, a subject of 
growing interest and importance. Not the least valuable portion of the volume is Part II., which 
consists of instructions issued to their examining physicians by twenty-four representative companies of 
this country. As the proofs of these instructions were corrected by the directors of the companies, they 
form the latest instructions obtainable. If for these alone the book should be at the right hand of 
every physician interested in this special branch of medical science." — Tke Medical News. 

' ' The volume is replete with information and sug-gestions, and is a valuable contribution to the 
literature of the medical department of life underwriters' work." — Tke TJjiited States Review (In- 
surance Journal). 

13 



SERIES OE 

Manuals for Students and Practitioners, 



The aim of the Publisher is to furnish, in this Series of Manuals, a number of 
high-class works bj prominent teachers who are connected with the principal 
Colleges and Universities of this country ; the position and experience of each 
being a guarantee of the soundness and standard of text of the subject on which 
he writes. 

Especial care has been exercised in the choice of large, clear, readable type ; a 
high grade of slightly toned paper, of a shade particularly adapted for reading 
by artificial light ; high-class illustrations, printed in colors when necessary to a 
clear elucidation of the text ; and strong, attractive, and uniform bindings. 

The prices vary greatly ($1.00 to $2.50), it not being considered desirable to 
fix an arbitrary standard and pad the volumes accordingly. 

Now Ready— Fourth Edition. 

CONTAINING 

^^XHIIISTTS OIST I3ISSE]OTIO:iSr." 



ESSENTIALS OF ANATOMY AND MANUAL OF PRACTICAL DISSECTION. 

By CHARLES B. NANCREDE, M.D., 

Professor of Surgery and Clinical Surgery in the University of Michigan, Ann Arbor ; Corresponding 

Member of tlie Royal Academy of Medicine, Eome, Italy : late 

Surgeon Jefferson Medical College, etc. etc. 



Post 8to., nearly 500 pages^Trith Handsome Fall-page Lithographic Plates in Colors. Over 200 II lustrations. 



Price, Extra Cloth or Oilcloth for the Dissection Room, $2.00, net. 

No pains or expense has been spared to make this work the most exhaustive 
yet concise Student's Manual of Anatomy and Dissection ever published, either 
in this country or Europe. 

The colored plates are designed to aid the student in dissecting the m'uscles, 
arteries, veins, and nerves. For this edition the wood-cuts have all been speci- 
ally drawn and engraved, and an Appendix added containing 60 illustrations 
representing the structure of the entire human skeleton, the whole based on 
the eleventh edition of Gray's Anatomy, and forming a handsome post 8vo. 
volume of over 400 pages. 

14 



NOW READY. A M A IVT TT A T OTT" first edition 

SECOND EDITION REVISED. ^ iVi il. i\ U i^ J-i KJ £ EXHAUSTED IN SIX MONTHS. 



PRACTICE OF MEDICINE. 

By a. a. STEVENS, A.M., M.D., 

Instructor of Physical Diagnosis in the University of Pennsylvania and Demonstrator of Pathology in 

the Woman's Medical College of Philadelphia. 

Specially Intended for Students Preparing for Graduation and 

Hospital Examinations. 

Including the following sections : General Diseases, Diseases of the Digestive Organs, Diseases of 
the Respiratory System, Diseases of the Circulatory System, Diseases of the Nervous System, Diseases 
of the Blood, Diseases of the Kidneys, and Diseases of the Skin. Each Section is prefaced by a chapter 
on General Symptomatology. 

Post 8vo., 502 pages. Numerous Illustrations and Selected Formulae. 

JPrice, $2.50. 



Contributions to the Science of Medicine have poured in so rapidly during the last quarter 
of a century that it is well-nigh impossible for the Student, with the limited time at his dis- 
posal, to master elaborate treatises or to cull from them that knowledge which is absolutely 
essential. From an extended experience in teaching, the author has been enabled by classi- 
fication, the grouping of allied symptoms, and the judicious elimination of theories and 
redundant explanations, to bring within a comparatively small compass a complete outline 
of the Practice of Medicine. 



JUST READY. 



Medical Jurisprudence and Toxicology. 

By henry C. chapman, M.D., 

Professor of Institutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of 

Philadelphia. 

WITH THIRTY-SIX ILLUSTRATIONS, SOME OP WHICH ARE IN COLORS. 

POST 8vo., 232 PAGES. 
Price, $1.25 net. 



For many years there has been a demand from members of the medical and legal profes- 
sions for a medium-sized work on this most important branch of Medicine. The necessarily 
prescribed limits of the work permit only the consideration of those parts of this extensive 
subject which the experience of the author as coroner's physician of the city of Philadelphia 
for a period of six years leads him to regard as the most material for practical purposes. 

Particular attention is drawn to the illustrations, many being produced in colors, thus 
conveying to the layman a far clearer idea of the more intricate cases. 

15 



JUST ISSUED. 

NURSING: 

ITS FRINOIPLES A-ISTD PRACTICE. 

By ISABEL ADAMS HAMPTON, 

Graduate of the New York Training School for Nurses attached to Bellevue Hospital; Superintendent 

of Nurses and Principal of the Training School for Nurses, Johns Hopkins Hospital, Baltimore, 

Md. ; Late Superintendent of Nurses, Illinois Training School for Nurses, Chicago, 111. 

In one Tery handsome 12mo. volume of 484 pages, profusely illustrated. 
rrice. Cloth, $2.00 net. 

This entirely new work on the important subject of nursing is at once compre- 
hensive and systematic. It is written in a clear, accurate, and readable style, suit- 
able alike to the student and the lay reader. Such a work has long been a desiderata 
with those intrusted with the management of hospitals and the instruction of nurses 
in training schools. It is also of especial value to the graduated nurse who desires 
to acquire a practical working knowledge of the care of the sick and the hygiene of 
the sick-room. 

The author has had considerable experience as superintendent of training schools 
for nurses and hospital management, and brings to her task a mind thoroughly equip- 
ped to make the subject attractive as well as scientific and instructive. 

Thoroughly attested and approved processes in practical nursing only have been 
given, particularly in antiseptic surgery, and the minutest details regarding the nurse's 
technique have been explained. 

Illustrations to elucidate the text have been freely used throughout the book, and 
will be found of material help in showing the forms of modern appliances for the 
hospital ward and sick-room, the registration of temperature, daily records, etc. 

Maryland Medical Journal, August 26, 1893 

We may be sure of the thoroughness of the author's knowledge of her theme. . . . She 
is equally skilful as a writer, presenting her subject in a clear, concise manner, and exhibit- 
ing that most desirable of all traits in a teacher, the ability to follow the newest and most 
advanced methods, with due respect to broad and judicious conservatism. 

Ontario Medical Journal, August, 1893. 

Seldom have we perused a book upon the subject that has given us so much pleasure as 
the one before us. No superintendent of a training school should neglect to read it at least 
once ; head nurses may refer to it more frequently, while junior nurses will profit much by a 
careful study of it. We would strongly urge upon the members of our own profession the 
need of a book like this, for it will enable each of us to become a training school in himself. 

The Churchman. 

Even a layman can appreciate the painstaking minuteness of detail which has been ex- 
pended upon this volume, the clearness of statement, and the methodical arrangement. 
Valuable for those who are contemplating nursing as a profession, as exhibiting the work of 
any ordinary two years' course in a training school. 

Toronto Globe, July 23, 1893. 

A book of great value. Every detail is discussed clearly and intelligently. Full of sound 
teaching and advice. 

Hahnemannian Monthly, Sept. 1893. 

The book may be characterized as a most excellent manual for the study of nursing, none 
being better. 

16 



NOW READY. 



NOTES ON THE NEWER REMEDIES. 

THEIR 

Therapeutic Applications and Modes of Administration. 

By DAYID CERN^A, M.D., Ph.D., 

Demonstrator of and Lecturer ou Experimental Therapeutics in tlie Uuiver^ty of Pennsylvania. 

POST OCTAVO, 175 PAGES. 
Brice, $1,25. 

The work takes up in alphabetical order all the Newer Remedies, giving their physical properties 
solubility, therapeutic applications, administration, and chemical formula. ' 

It will, in this way, form a very valuable addition to the various works on Therapeutics now in existence. 
_ Chemists are so multiplying compounds, that if each compound is to be thoroughly studied, investiga- 
tions must be carried far enough to determine the practical importance of the new agents. 

Brevity and conciseness compel the omission of all biographical references. 



IN ACTIVE PREPARATION— NEARLY READY. 



A Manual of Materia Medica and Therapeutics. 

By a. A. STEVENS, A.M., M.D., 

Instructor of Physical Diagnosis in the University of Pennsylvania and Demonstrator of Pathology in 

the Woman's Medical College of Philadelphia. 



In Preparation, 



Dose-Book and Manual of Prescription-Writing. 

By E, Q. THOKNTON, M.D., 

Demonstrator of Therapeutics, Jefferson Medical College, Philadelphia. 

IN ACTIVE PREPARATION. 



Methods of Preventing and Correcting 

DEFORMITIES OF THE BONES AND JOINTS. 



A Handbook of Practical Orthopedic Surgery. 



By H. AUGUSTUS WILSON^, M.D., 

Professor of General and Orthopedic Surgery, Philadelphia Polyclinic; Clinical Professor of Orthopedic 
Surgery, Jefferson Medical College, Philadelphia, etc., etc. 



The aim of the author will be to provide a book of moderate size containing comprehensive details 
that will enable general practitioners to thoroughly understand the mechanical features of the many 
forms of congenital and acquired deformities of the bones and joints. 

The mechanical functions that are impaired will be considered first as to prevention, as of primary- 
importance, and following this will be described the methods of correction that have been proved prac- 
tical by the author. Operative procedures will be considered from a mechanical standpoint as well as 
surgically. Prominence will be given to the mechanical requirements for braces and artificial limbs, 
etc., with description of the methods for constructing the simplest forms, whether made of plaster of 
Paris, felt, leather, paper, steel, or other materials, together with the methods of readjustment to suit 
the changes occurring during the progress of the case. 

An important feature of the book will be the practical application of remedial gymnastics and move- 
ments in the prevention or recovery of lost mechanical functions of the muscles when they have pro- 
duced or tend to produce bone or joint deformities. 

A very large number of original illustrations will be used to make descriptions clearer. 

17 



SYLLABUS OF OBSTETRICAL LECTURES 

IN THE 

MEDICAL DEPARTMENT, UNIVERSITY OF PENNSYLVANIA. 

By EICHARD C. KORRIS, A.M., M.D., 
Demonstrator of Obstetrics in the University of Pennsylvania. 
THIRD EDITION, THOROUGHLY REVISED AND ENLARGED. 

CROWN 8vo. 
Price, Cloth, Interleaved for Notes, $2.00 net. 

The New York Medical Record of April 19, 1890, referring to this book, says : " This modest little 
work is so far superior to others on the same subject that we take pleasure in calling attention briefly 
to its excellent features. Small as it is, it covers the subject thoroughly, and will prove invaluable to 
both the student and the practitioner as a meanj of fixing in a clear and concise form the knowledge 
derived from a perusal of the larger text-books. The author deserves great credit for the manner in 
which he has performed his work. He has introduced a number of valuable hints which would only 
occur to one who was himself an experienced teacher of obstetrics. The subject-matter is clear, forcible, 
and modern. We are especially pleased with the portion devoted to the practical duties of the accoucheur, 
care of the child, etc. The paragraphs on antiseptics are admirable : there is no doubtful tone in the 
directions given. No details are regarded as unimportant ; no minor matters omitted. We venture to say 
that even the old practitioner will find useful hint's in this direction which he cannot afford to despise." 

SAMDEES' POCKET MEDICAL LEXICON; 

OR, 

DICTIONARY OF TERMS AND WORDS USED IN MEDICINE AND SURGERY. 

By 3011^ M. KEATI:N^G, M.D., 

Editor of "Cyclopgedia of Diseases of Children," etc. ; Author of the "New Pronouncing Dictionary of 

Medicine," 

AND 

HENRY HAMILTOlsr, 

Author of ''A New Translation of Virgil's ^neid into English Verse;" Co-author of a "New Pro- 
nouncing Dictionary of Medicine," 

32nio. ; 282 Pages. 
PRICE, 75 CENTS, CLOTH ; $1.00, LEATHER TUCKS. 

This new and comprehensive work of reference is the outcome of a demand for a more modern hand- 
book of its class than those at present on the market, which, dating as they do from 1855 to 1884, are 
of but trifling use to the student by their not containing the hundreds of new words now used in current 
literature, especially those relating to Electricity and Bacteriology. 

By henry J. GARRIGUES, A.M., M.D., 

Profeesor of Obstetrics in the New York Post-Graduate Medical School and Hospital ; Gynaecologist to 

St. Mark's Hospital in New York City; Gynaecologist to the German Dispensary in the City of 

New York ; Consulting Obstetrician to the New York Infant Asylum ; Obstetric Surgeon 

to the New York Maternity Hospital ; Fellow of the America ■ Gynaecological 

Society ; Fellow of the New York Academy of Medicine ; Pi'esident of 

the German Medical Society of the City of New York, etc., etc. 



In One Very handsome Octavo Volume of about 700 pages, Illustrated by Numerous 
Wood-cuts and Colored Plates. Price, Cloth, $4.00 ; Sheep, $5.00. 



A practical work on Gynaecology for the use of students and practitioners, written in a terse and 
concise manner. The importance of a thorough knowledge of the anatomy of the female pelvic organs 
has been fully recognized by the author, and considerable space has been devoted to the subject. The 
chapters on operations and treatment will be thoroughly modern, and will be based upon the large 
hospital and private practice of the author. 

The text is elucidated by a large number of illustrations and colored plates, many of them being 
original. 

If 



JUST ISSUED. 



A SYLLABUS OF LECTURES 



ON THE 



PRACTICE OF SURGEY, 

ARRANGED IN CONFORMITY WITH 

THE AMERICAN TEXT-BOOK OF SURGERY. 

BY 

NICHOLAS SENN, M.D., Ph.D., 

Professor of Surgery in Kush Medical College, Chicago, and in the Chicago Polyclinic. 



Price $2.00. 

This the latest work of its eminent anthor, himself one of the contributors 
to the " American Text-Book of Snrgery," will prove of exceptional value to 
the advanced student who has adopted that work as his text-book. It is not 
only the syllabus of an unrivalled course of Surgical Practice, but an epitome 
or supplement to the larger work. 

NOW READY— SECOND EDITION. 



AN OPERATION BLANK 



WITH 



Lists of Instruments, etc., required in various operations. 

Prepared by W. W. KEEK, M.D., LL.D. 

Professor of Principles of Surgery in the Jefferson Medical College, Philadelphia. 



Price per Pad, containingBlanks for 50 Operations, 50 Cents, net. 

A convenient blank, suitable for all operations, giving complete instruc- 
tions regarding necessary preparation of patient, etc., with a full list of dress- 
ings and medicines to be used. 

At the back of pad is a list of instruments used — viz. : general instruments, 
etc., required for all operations, and special instruments for surgery of the 
brain and spine, mouth and throat, abdomen, rectum, male and female genito- 
urinary organs, the bones, etc. etc. 

The whole forming a neat pad arranged for hanging on wall of surgeon's 
office or hospital operating-room. 



SAUNDERS' QUESTION COMPENDS. 

Now the Standard Authorities in Medical Literature 

WITH 

Students and Practitioners in every City of the United States 

and Canada. 



THE REASON WHY ! 

They are the advance guard of " Student's Helps" — that do help ; they are the leaders 
in their special line, ivell and authoritatively written hy able men, who, as teachers in the large 
colleges, know exactly what is wanted by a student preparing for his examinations. The judgment 
exercised in the selection of authors is fully demonstrated by their professional elevation. 
Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of them 
HAVE become Professors and Lecturers in their respective Colleges. 

Each book is of convenient size (5 by 7 inches), containing on an average 250 pages, pro- 
fusely illustrated and elegantly printed in clear, readable type, on fine paper. 

The entire series, numbering twenty-three subjects, has been kept thoroughly revised 
and enlarged when necessary, many of them being in their third and fourth editions. 

TO SUM UP. 

Although there are numerous other Quizzes, Manuals, Aids, etc., in the market, none of 
them approach the " Blue Series of Question Compends," and the claim is made for the fol- 
lowing points of excellence : — 

1. Professional standing and reputation of authors. 

2. Conciseness, clearness, and standard of text. 

3. Size of type, quality of paper and binding. 

No. 1. 

ESSENTIALS OF PHYSIOLO&Y. 

By H. a. hare, M.D., 

Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia; 

Physician to St. Agnes' Hospital and to the Medical Dispensary of the Children's Hospital; 

Laureate of the Royal Academy of Medicine in Belgium, of the Medical Society of London, etc. ; 

Secretary of the Convention for the Revision of the Pharmacopoeia, 1890. 

THIRD EDITION, 

Revised and Enlarged by tlie addition of a series of handsome Plate 
Illustrations taken from the celebrated '* Icones Nervorum 
Capitus" of Arnold. Crown 8vo. 230 pag-es. IS^umerous 

Illustrations. 

Price, Cloth, $1.00 net. Interleaved for notes, $1.25 net. 



Uuiverstity Medical Magazine. — "Dr. Hare has admirably succeeded in gathering together a 
series of questions which are clearly put and tersely answered." 

Buffalo Medical and Surgical Reporter. — "The subject of Physiology is concisely and accurately 
considered." 

Joiirnalof American Medical Association. — "■ An exceedingly useful little compend. The author has 
done his work thoroughly and well. The plates of the cranial nerves from Arnold are superb." 

20 



No. 2. 

Essentials of Surgery. 

CONTAINING ALSO, 

Venereal Diseases, Surgical Landmarks, Minor and Operative Surgery, and a Complete 
Description, together with full Illustrations, of the 
Handkerchief and Roller Bandage. 

By EDWARD MARTIN, A.M., M.D., 

Clinical Professor of Genito-Urinary Diseases, Instructor in Operative Surgery, and Lecturer on 

Minor Surgery, University of Pennsylvania ; Surgeon to the Howard Hospital ; 

Assistant Surgeon to the University Hospital, etc. etc. 

FIFTH EDITION. CROWIV 8vo. 334 PAGES, PROFUSELY ILLUSTRATED. 

Considerably enlarged by an Appendix containing full directions and prescriptions for the preparation 

of the various materials used in ANTISEPTIC SUKGERY ; also several hundred 

recipes covering the medical treatment of surgical affections. 

PRICE, CLOTH, . . $1.00. INTERLEAVED FOR NOTES, . . $1.25. 

Boston Medical and Surgical Journal. — "Written to assist the stvident, it will be of undoubted value 
to the practitioner, containing as it does the essence of surgical work." 

Medical and Surgical Reporter. — "Contains all necessary essentials of modern surgery in a compara- 
tively small space. Its style is interesting and its illustrations admirable." 

No. 3. 

Essentials of Anatomy. 

Including the Anatomy of the Viscera. 

By CHARLES B. NANCREDE, M.D., 

Professor of Surgery and of Clinical Surgery in the University of Michigan, Ann Arbor ; Corresponding 

Member of the Eoyal Academy of Medicine, Eome, Italy ; Late Surgeon 

to the Jefferson Medical College, etc. etc. 

FOURTH EDITION. CROWN 8vo. 380 PAGES, 180 ILLUSTRATIONS. 

Enlarged by an Appendix containinp^ over Sixty IHustrations of the Osteology of the 
Human Body, The whole based upon the last (eleventh) edition of 

PRICE, CLOTH, . . $1.00. INTERLEAVED FOR NOTES, . . $1.25. 

America?i Practitioner and News, Lotiisville, Kentuchy. — " Nancrede's Anatomy. — Truly such a 
book as no student can afford to be without." 

University Medical Magazine.—" The questions have been wisely selected, and the answers accu- 
rately and concisely given." 

_____ 

ESSEITIALS OE lEDICAL CHEMISTRY 

ORGANIC AND INORGANIC. 

CONTAINING ALSO, 

Questions on Medical Physics, Chemical Physiology, Analytical Processes, 

Urinalysis, and Toxicology. 

By LAWKENCE WOLFF, M.D., 

Demonstrator of Chemistry, Jefferson Medical College : Visiting Physician to German Hospital 
of Philadelphia ; Member of Philadelphia College of Pharmacy, etc. etc. 

FOURTH and REVISED EDITION, WITH AN APPENDIX. CROWN 8vo. 212 PAGESo 

Brice, Cloth, $1,00, Interleaved for Notes, $1,25, 

Pharmaceutical Era. — " Wolff's Chemistry. — The scope of this work is certainly equal to that of the 
best course of lectures on Medical Chemistry." 

Medical and Surgical Reporter. — "We could wish that more books like this would be written, in 
order that medical students might thus early become more interested in what is often a difficult and 
uninteresting branch of medical study." 



No. 5. 

ESSENTIALS OF OBSTETRICS. 

By W. easterly ASHTON, M.D., 

Professor of Gynaecology in the Medico-Chirurgical College of Philadelphia ; Obstetrician to the 

Philadelphia Hospital. 

THIRD EDITION, THOROUGHLY REVISED AND ENLARGED: 

Crown 8vo. ; 244 Pages; 75 Illustrations. 
Price, Cloth, $1.00. Interleaved for Notes, $1.25. 

Sotithern Practitioner. — "An excellent little volume containing correct and practical knowledgeo 
An admirable compend, and the best condensation we have seen."' 

Chicago Medical Times. — "Of extreme value to students, and an excellent little book to freshen up 
the memory of the practitioner." 



No. 6. 

Essentials of Pathology and Morbid Anatomy. 

BY 

C. E. ARMAND SEMPLE, B.A., M.B. Cantab., I.S.A., M.R.C.P. lond., 

Physician to the Northeastern Hospital for Children, Harkney ; Professor of Vocal and Aural Physi- 
ology and Examiner in Acoustics at Trinity College, London, etc. etc. 

Crown 8vo. ; 174 Pages; Illustrated; Sixth Thousand. 
Price, Oloth, $1.00. Interleaved for Notes, $1.25. 

Indiana Medical Joiirnal, December, 1889. — "Semple's Pathology and Morbid Anatomy. — An 
excellent compend of the subject from the points of view of Green and Payne." 

Gincinn.ati Medical News ^ November, 1889. — "Semple's Pathology and Morbid Anatomy. — A valu- 
able little volume — truly a imdtuin in parvo.*'' 

No. 7, 

Essentials of Materia Medioa, Therapeutics, 



AND 



PRESCRIPTION WRITING. 

By henry MOKRIS, M.D., 

Late Demonstrator, Jefferson Medical College ; Fellow College of Physicians, Philadelphia ; Co-Editor 
Biddle's Materia Medica ; Visiting Physician to St. Joseph's Hospital, etc. etc. 

Second Edition ; Crown 8vg. ; 250 Pages, 

Price, Cloth, $1.00, Interleaved for Notes, $1.25. 

Medical and Surgical Reporter, October, 1889. — " Morris' Materia Medica and Therapeutics. — One of the 
best compends in this series. Concise, pithy, and clear, well suited to the purpose for which it is prepared. " 

Gaillard's Medical Journal, November, 1889. — "Morris' Materia Medica. — The very essence of 
Materia Medica and Therapeutics boiled down and presented in a clear and readable style." 

'Buffalo Medical a7id Surgical Journal, January, 1890. — "Morris' Materia Medica. — The subjects 
are treated in such a unique and attractive manner that they cannot fail to impress the mind and 
instruct in a lasting manner. " 

. 22 



Nos. 8 and 9. 

ESSENTIALS OF PEACTICE OF MEDICINE. 

By henry MOERIS, M.D., 

Author of " Essentials of Materia Medica," etc. 

With an Appendix on the Clinical and Microscopical Examination of Urine. 

By LAWRENCE WOLFF, M.D., 

Author of " Essentials of Medical Chemistry," etc. 

COLORED (VOGEL) URINE SCALE AND NUMEROUS PINE ILLUSTRATIONS. 

Tliird E]ditioii, Enlarged toy some Three Hundred Essential Formulse, selected from the 
-writings of tiie most eminent authorities of the Medical Profession. 

COLLECTED AJSTD AREANGED BY 

WILLIAM M. POWELL, M.D., 

Author of "Essentials of Diseases of Children." 

rost Svo.f 460 pages. Price, Cloth, $2.00. Medical Sheep, $2,50. 

America?i Fractitio7ier aiid Neivs, Louisville, Ky. — " The teaching is sound, the presentation graphic, 
matter as full as might be desired, and the style attractive." 

Medical Brief, St. Louis. — " A first-class practice of medicine boiled down, and giving the real essen- 
tials in as few words as is consistent with a thorough understanding of the subject.'* 

No. 10. 

ESSENTIALS OF GYNiECOLOGY. 

By EDWm B. CRAGIN, M.D., 

Attending Gynaecologist, Roosevelt Hospital, Out- Patients' Department ; Assistant Surgeon, New York 

Cancer Hospital, etc. etc. 



SECOND EDITION. 
Crown 8vo. ; i86 Pages ; 58 Fine Illustrations. 

Price, Cloth, $1.00. Interleaved for Notes, $1.25. 

Medical and Surgical Reporter. — " Craigin's Essentials of Grynaecology. — This is a most excellent 
addition to this series of question compends, and properly used will be of great assistance to the student 
in preparing for examination. Dr. Craigin is to be congratulated upon having produced in compact 
form the Essentials of Gynaecology. The style is concise, and at the same time the sentences are well 
rounded. This renders the book far more easy to read than most compends, and adds distinctly to its 
value." 

No. 11. 

ESSENTIALS OF DISEASES OF THE SKIN. 

By HEN"RY W. STELWAGOK, M.D., 

Clinical Lecturer on Dermatology in the Jefferson Medical College, Philadelphia; Phvsician to the Skin 

Service of the Northern Dispensary; Dermatologist to Philadelpliia Hospital ; Physician to 

Skin Department of the Howard Hospital : Clinical Professor on Dermatology 

in the Woman's Medical College, Philadelphia, etc. etc. 

SECOND EDITION. 
Crown 8vo. ; 262 Pages ; 74 Illustrations, many of ■which are Original. 

Price, Cloth, $1.00. Interleaved for Notes, $1.25. 

Medical Record, New York. — '*An immense amount of literature has been gone over and judiciously 
condensed by the writer's skill and experience." 

New York Medical Journal. — " The little book now before us is well entitled 'Essentials of Derma- 
tology,' and admirably answers the purpose for which it is written. The experience of the reviewer 
has taught him that just such a book is needed. '' 

23 



No. 12. 
ESSENTIALS OF 

Minor Surgery, Bandaging, 

AlSfD 

VENEREi^LL DISEi^SES. 

By EDWARD MARTIN, A.M., M.D., 

Author of "Essentials of Surgery," etc. 
SECOND EDITION. 

CROWN 8vo; THOROUGHLY REVISED AND ENLARGED. 
Price, Cloth, $1.00, Interleaved for Notes, $1.25, 

A'merican Practitioner and News, Louisville. — "Characterized by the same literary excellence that 
has distinguished previous numbers of this series of compends. " 

Medical News, Philadelphia, January 10, 1891. — " Martin's Minor Surgery, Bandaging, and Vene 
real Diseases. — The best condensation of the subjects of Avhich it treats yet placed before the profession. 
The chapter on Genito Urinary Diseases, though short, is sufficiently complete to make them thoroughly 
acquainted with the most advanced views on the subject." 



No. 13. 
ESSENTIALS OF 

Legal Medicine, Toxicology, 

AND 

HYGMEISTE. 

By C. B. ARMAND SEMPLB, M.D., 

Author of '"Essentials of Pathology and Morbid Anatomy." 

CROWN 8vo. 5 212 PAGES ; 130 ILLUSTRATIONS. 

Price, Cloth, $1,00, Interleaved for Notes, $1.25. 

Smitkern Practitioner, Nashville. — " The leading points, the essentials of this too much neglected 
portion of medical science, are here summed up systematically and clearly. ' ' 

No. 14. 

Essentials of Refraction and Diseases of the Eye. 

By EDWARD JACKSON, A.M., M.D., 

Professor of Diseases of the Eye In the Philadelphia Polyclinic and College for Graduates in Medicine.; 

Member of the American Ophthalmological Society; Fellow of the College of Physicians 

of Philadelphia; Fellow of the American Academy of Medicine, etc. etc. 

AND 

Essentials of Diseases of the Nose and Throat. 

By E. BALDWIN GLEASON, M.D., 

Assistant in the Nose and Throat Dispensary of the Hospital of the University of Pennsylvania; 

Assistant in the Nose and Throat Department of the Union Dispensary ; Member 

of the German Medical Society. Philadelphia; Member 

of the Polyclinic Medical Society, etc. etc. 

TWO VOLUMES IN ONE. CROWN 8vo. 268 PAGES, PROFUSELY ILLUSTRATED. 
Price, Cloth, $1,00. Interleaved for Notes, $1,25, 

University Medical Magazine, Philadelphia, October, 1890. — "Jackson and Gleason's Essentials of 
Diseases of the Eye, Nose, and Throat. — The subjects have been handled with skill, and the student 
who acquires all that here lays before him will have much more than a foundation for future work." 

New Yorh Medical Record, November 15, 1890. — " Jackson and Gleason on Diseases of the Eye, Nose, 
and Throat. — A valuable book to the beginner in these branches, to the student, to the busy practitioner, 
and as an adjunct to more thorough reading. The authors are capable men, and as successful teachers 
know what a student most needs." 

24 



No. 15. 

Essentials of Diseases of Children. 

By WILLIAM M. POWELL, M.D., 

Attending Physician to tlie Mercer House for Invalid Women, at Atlantic City, N. J. ; Late Pliysician 
to the Clinic for the Diseases of Children in the Hospital of the University of Pennsyl- 
vania and St. Clement's Hospital: Instructor in Physical Diagnosis in the 
Medical Department of the University of Pennsylvania. 

Crown 8vo.; 216 Pages. 
Price, Cloth, $1.00. Interleaved for Notes, $1.35. 

American Practitioner and News, Louisville, Ky. — "Powell's Diseases of Children. — This work is 
gotten up in the clear and attractive style that characterizes the Saunders' Series. It contains in 
appropriate form the gist of all the best works in the department to which it relates." 

Annals of GyncECology, Philadelphia. — "Powell's Diseases of Children. — The book contains a series 
of important questions and answers, which the student will find of great utility in the examination of 
children." 

No. 16. 

Essentials of Examination of Urine. 

By LAWRENCE WOLFF, M.D., 

Author of "Essentials of Medical Chemistry," etc. 

COLORED (YOGEL) URINE SCALE AND NUMEROUS ILLUSTRATIONS. 

OEOWN 8vo. 
Price, Cloth, 75 Cents. 

University Medical Magazine. — '-Wolff's Examination of the Urine. — A little work of decided 
value." 

Medical Record, New York. — "Wolff's Examination of Urine. — A good manual for students, well 
written, and answers, categorically, many questions beginners are sure to ask." 

No. 17. 

Essentials of Diagnosis. 

By SOLOMOK SOLIS COHEK, M.D., 

Professor of Clinical Medicine and Applied Therapeutics in the Philadelphia Polyclinic, 

AND 

AUGUSTUS A. ESHNEE, M.D., 

Instructor in Clinical Medicine, Jefferson Medical College, Philadelphia. 

POST 8vo. ; 382 PAGES. 

55 Illustrations, some of which are Colored, and a Frontispiece. 

Price, $1.50 net, 

Medical Record, New York. — "A good book for the student, properly written from their standpoint, 
and confines itself well to its text." 

American Jouryial of Medical Sciences. — "Concise in the treatment of the subject, terse in expression 
of fact. . . . The work is reliable, and represents the accepted views of clinicians of to-day." 

International Medical Magazine.—'' The subjects are explained in a few well-selected words, and the 
required ground has been thoroughly gone over." 

25 



No. 18. 

ESSENTIALS OF PRACTICE OF PHARMACY. 

By LUCIUS E. SAYRE, M.D., 

Professor of Pharmacy and Materia Medica in the University of Kansas. 

Crown 8vo., 171 pages. 
Price, Cloth, $1.00. Interleaved for Notes, $1.25. 



Albany Medical Annals, Albany, N. Y. — " Sayre's Essentials of Pharmacy covers a great deal ot 
ground in small compass. The matter is well digested and arranged. The research questions are a 
valuable feature of the book." 

Natiojial Drtig Register, St. Louis, Mo. — " Sayre's Essentials of Pharmacy. — The best quiz on Phar- 
macy we have yet examined." 

No. 20. 

ESSENTIALS OF BACTEE,IOLO&T. 

A Concise and Systematic Introduction to the Study of 

Micro-organisms. 

By M. Y. ball, M.D., 

Assistant in Microscopy, Niagara University, Buffalo, N. Y. ; late resident Physician German Hospital, 

Philadelphia, etc. 

ISXCOOIVO EIOITION llIi:VlSEI>. 

Crown 8vo, 150 Pages. 77 Illustrations and 5 Plates. Some in Colors. 
Price, Cloth, $1.00. Interleaved for Notes, $1,25. 



Medical Neivs, Philadelphia. — "The amount of material condensed in this little book is so great, 
and so accurate are the formulae and methods, that it will be found useful as a laboratory hand-book.'" 

Pacific Record of Medicine and Surgery, San Francisco. — " Bacteriology is the keynote of future 
medicine, and every physician who expects success must familiarize himself with a knowledge of 
Germ-life — the agents of disease. This little book, with its beautiful illustrations, will give the stu- 
dents, in brief, the results of years of study and research, unaided." 

No. 21. 

Essentials of Nervous Diseases and Insanity, 

THEIR SYMPTOMS AND TREATMENT. 

By JOHN C. SHAW, M. D., 

Clinical Professor of Diseases of the Mind and Nervous System, Long Island College Hospital Medical 

School; Consulting Neurologist to St. Catherine's Hospital and Long Island College Hospital; 

Formerly Medical Superintendent King's County Insane Asylum. 

Second Edition, Crown 8vo, 186 pages, 48 Original Illustrations, 

Mostly selected from the Author's private practice. 

JPHce, Cloth, $1.00. Interleaved for Notes, $1*25, 



Boston Medical and Surgical Journal — " Clearly and intelligently written." 

Medical Brief Dec. 1891. — "A valuable addition to this series of compends, and one that cannot 

fail to be appreciated by all physicians and students. ' ' 

Times and Register, New York and Philadelphia. — "Dr. Shaw's Primer is excellent as far as it 

goes. The engravings are well executed and very interesting." 

26 



No. 22. 

ESSENTIALS OP PHYSICS. 

By FRED. J. BROCK WAY, M.D., 

Assistant Demonstrator of Anatomy in the College of Physicians and Surgeons, New York, 

CROWN 8vo, 320 PAGES. 155 FINE ILLUSTRATIONS. 
Price, Cloth, $1.00, Net. Interleaved for Notes, $1.25, Net. 

American Practitioner atid Nevjs, Louisville, Ky. — " The publisher has again shown himself as fortu- 
nate in his editor as he ever has been in the attractive style and make-up of his compends. "' 

Medical Record, New York. — " Contains all that one need know of the subject, is well written, and 
is copiously illustrated. ' ' 

Medical News, Philadelphia. — "The author has dealt with the subject in a manner that will make 
the theme not only comparatively easy, but also of interest." 

No. 23. 

ESSENTIALS OF MEDICAL ELECTRICITY. 

By D. D. STEWART, M.D., 

Demonstrator of Diseases of the Nervous System and Chief of the Neurological Clinic in the Jefferson 
Medical College ; Physician to St. Mary's Hospital and to St Christopher's Hospital for Children, etc. 

AND 

E. S. LAWRAisTCE, M.D., 
Chief of the Electrical Clinic and Assistant Demonstrator of Diseases of the Nervous System in the 

Jefferson Medical College, etc. 

Crown 8vo., 148 Pages. 

SIXTY-FIVE ILLUSTRATIONS. 

Price, Cloth, $1.00. Interleaved for Notes, $1.25. 

Medical arid Surgical Journal, Boston. — "Clearly written, and affords a safe guide to the beginner 
in this subject." 

Medical Record, New York. — '• The subject is presented in a lucid and pleasing manner." 

The Hospital, London, England. — " A little work on an important subject, which will prove of great 
value to medical students and trained nurses who wish to study the scientific as well as the practical 
points of electricity." 

Annals of Stirgery, Philadelphia. — " The selection and arrangement of material are done in a skilful 
manner. It gives, in a condensed form, the principles and science of electricity and their application 
in the practice of medicine." 

IN ACTIVE PREPARATION— READY SHORTLY, 



A Manual of Surgery— G-eneral and Operative. 

By J0H]S" CHALMERS DA COSTA, M.D. 

Demonstrator of Surgery, Jefferson Medical College. 



A new manual of the Principles and Practice of Surgery, intended to meet the growing 
demand for students and others for a medium-sized work which will embody all the newer 
methods of procedure detailed in the larger text-books. 

27 



OUTLIJXES 



OF 



A SYLLABUS OF LEOTUEES 

DELIVERED AT LONG ISLAND COLLEGE HOSPITAL 

BY 

CHAKLES JEWETT, A. M, M. D., 

Professor of Obstetrics and Pediatrics in the College, and Obstetrician 

to the Hospital. 

EDITED BY 

HAEOLD F. JEWETT, M.D. 



Post 8vo. 264- Pages. 

PRICE, $2.00. 

Sent post-paid on receipt of price. 



This book treats only of the general facts and principles of ob- 
stetrics ; these are stated in concise terms and in a systematic and 
natural order of sequence, theoretical discussion being as far as 
possible avoided; the subject is thus presented in a form to be 
most easily grasped and remembered by the student. Special at- 
tention has been devoted to practical questions of diagnosis and 
treatment, and in general particular prominence given to facts 
which the student most needs to know. The condensed form of 
statement and the orderly arrangement of topics adapt it to the 
wants of the busy practitioner as a means of refreshing his knowl- 
edge of the subject and a handy manual for daily reference. 

W. B. SAUNDERS, Publisher, 

925 Walnut St., Philadelphia, Pa. 



LRb ?6 



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